Is there a justification of conducting clinical audit in the endodontic treatment outcomes?

OBJECTIVE: The aim of this study is to determine the role of clinical audit in improving endodontic treatment outcomes.
MATERIALS AND METHODS: An audit at the department of endodontics at dental specialty centre kingdom of Saudi Arabia was carried out. The audit was conducted by developing endodontics treatment and success predictors based on evidence, that can be measured for endodontic care. A total of 12 months' data was examined from the previous dental records. Ten clinical cards were which included root canal treatment were selected. The audit was carried out for a minimum of 50 teeth and a maximum of 200 teeth. The radiographs of record cards were studied and a single dentist completed the audit tool.
RESULTS: The vitality test was performed in 1.98% cases, intra-canal medicament was used and named in 3.96% cases, 3.96% the teeth were extracted due to endodontic failure. Further, in 6.93% of the cases that were identified had certain spaces but overall root canal filling was evaluated as satisfactory.
CONCLUSION: The vitality test, type of intracanal medicament, and assessment of root canal filling were not done, but there was an overall performance of predictors for endodontic treatment. Copyright:

INTRODUCTION

Clinical audit is the method of improving the patient care.[1] Clinical audit cycle follows organized process that enables to create best practice, determining standard patient care and taking necessary action to progress patient care and development achieved. The clinical audit aims to advance the level of patient care quality after the changes have been introduced. In general, it helps to identify the loop holes and flaws in providing care in the system and thereby improving the treatment outcomes of the patient. It is commonly done by having clear inclusion criteria, structure of the practice, processes and outcomes against explicit criteria.

The endodontic treatment is performed based on clinical indication to preserve teeth, its function and to avoid further complications without any bias to patient's health.[2] To achieve a good endodontic practice, the clinician must follow the guidelines on the standard of patient care proposed by the European Society of Endodontology.[2] The minimally invasive therapies like halls technique, indirect and direct pulp capping, sandwich technique and pulpotomy etc. must be diagnosed and treated with proper root canal treatment by every dental practitioner.[3] Difficult cases which can't be managed by the clinicians must be referred to the dental specialist of the field, who has trained and developed the expertise.4 The success of non-surgical endodontics is between 55%-93%.[5] Though the scientific information on the treatment done by the general dentists and specialists available but there was paucity of literature on the validation of clinical audit conducted after secondary data collection.

Therefore, the objective of this study was to conduct clinical audit in improving endodontic treatment.

MATERIALS AND METHODS

The endodontic audit is carried out at Dental Speciality Centre at Saudi Arabia. A prior permission and ethical approval to conduct was taken from the human ethical department (no. 201700092). The endodontic audit within the hospital was conducted and an initial audit in November 2017 by utilizing the audit tool. Based on the evidence associated to the measurable features of care, the tool was developed using valid criteria.[13] In both November 2017, 20 clinicians from the department of endodontics were involved in the audit. A total of 12-month data were examined from the previous dental records, and from each clinician, ten cards were selected which had root canal treatment. The objective was to audit 50 teeth minimum and 200 maximum. The radiographs of record card were studied, respectively, and a single dentist completes the audit tool.

An initial clinical audit was conducted using the following four criteria:

X-ray images engaged during endodontic treatment (selection criteria in endodontic radiography and grading of radiograph)

Outcome

The clinical audit helps to determine the quality of treatment delivered and also to determine the treatment outcomes. It also helps to take practical measures to improve the quality of health-care delivery.

RESULTS AND DISCUSSION

Our study results have found that, among the reports that have been assessed there was compliance in the quality of care in endodontic treatment [Tables 1-4]. However, the objective predictors related to vitality test, type of intracanal medicament, and assessment of root canal filling were not done. The vitality test was done in 1.98% cases, intracanal medicament was used and named in 3.96%, the tooth was extracted due to endodontic failure in 3.96% cases, and in 6.93% cases identified had certain spaces, but total root canal filling was evaluated as satisfactory [Tables 1-4]. The initial approach to improve the endodontic treatment outcomes was to provide a feedback to the clinicians on results of the audit. Later, the whole team involved in endodontic treatment was addressed on the outcome of the audit and suggestions supported by Cannell.[6] Dentists involved in endodontic treatment recorded the signs, symptoms, and a complete clinical examination such as swelling, sinus, and pain on percussion in 100% cases [Table 1]. However, the vitality test was recorded in only 1.98% cases. Vitality testing plays an important role in making diagnosis related to endodontic lesions. The test should be combined or conducted as an adjunct to other tests that help clinicians to arrive at diagnosis. The rubber dam was used in 100% cases, and the alternative methods of isolation such as use of parachute chains were mentioned in 99.50% cases. The center has allotted different responsibilities to the dentists and specialists in endodontics. First, the access opening was done by the general dentists and give temporary restoration. During this time, they have used the alternative methods of isolation such as parachute chains. Later, the specialists in endodontics complete endodontic therapy under rubber dam isolation. All these details were recorded in the case paper of the patient. In some studies, such as Slaus and Bottenberg explained the gap between the clinical practice and university teaching with regard to the rubber dam use.[7] The clinicians mentioned they used intra-canal medicament in 3.96% cases, but the type of intra-canal medicament used was not reported [Table 1].

Table 1

Clinical endodontic treatment standards

Noted records	Percentage achieved (n=202)
A complete clinical examination such as swelling, sinus, and pain on percussion had been performed on endodontically involved tooth	100.00
A vitality test performed	1.98
Rubber dam was used	100.00
When rubber dam was not use other aids such as parachute chain was recorded in the notes	99.50
Use of irrigation agent and named	99.50
Placement of intracanal medicament and named	3.96
Use of apex locater	98.51
The working length had been recorded	99.50

Table 4

Clinical results and unfavorable events

Event	Percentage achieved (n=202)
Extraction of tooth advised	3.96
Instrument breakage during treatment	14.35
Patient complaint of pain, lost dressing	38.12
Placement of permanent plastic restoration	60.40
In posterior tooth, a cast cuspal coverage restoration had been placed	90.00

A preradiograph was taken, and the report of findings was mentioned on the case paper. The working length, gutta-percha, postobturation radiograph, and the quality of radiograph achieved were of good quality [Table 2]. A tooth with apical periodontitis shows the significant influence in relation to the level of root filling in relation to the root apex [Table 3]. Further, nonvital teeth showing apical periodontitis showed about 94% success rate with proper instrumentation and filling is done till apex, whereas a success rate of 76% was identified in the teeth with similar preoperative condition in which overfilling was done, and those were filled >2 mm short to the root apex had a 68% of achievement level. This shows the importance of proper instrumentation, irrigation at the apical third portion of 0–2 mm short of apex, and filling to this length.[8] New techniques and hands-on practice of latest methods are required with proper training in delivering endodontic treatment procedures. Further, it is advised that colleagues and the specialists should play a role as teachers as they have good insights of the endodontic practice. The continuing dental education programs must be easy and should be considered with differences in learners' requirements and working environment. To achieve successful implementation of change, the use of combination of different educational methods is advisable.[89]

Table 2

X-ray images engaged during the endodontic treatment

Radiographs	Percentage achieved (n=202)
An IOPA radiograph had been taken, preoperative for diagnosis	100.0
Record card had interpretation of the radiographic findings	99.50
Radiograph to identify working length had been taken	97.52
Radiograph to identify master gutta-percha had been taken	97.52`
Radiograph post obturation had been taken	100.00
Quality of radiograph was Grade A	100.00

IOPA: Intraoral periapical

Table 3

The standard of root canal filling as examined radiographically

The radiographic finding	Percentage achieved (n=202)
Obturation between 0 and 2 mm short from the radiographic apex	98.02
Obturation had extend beyond the radiographic apex	3.48
Obturation more than 2 mm from the radiographic apex	0.50
A good preparation and well-condensed root canal filling	93.56
Identified certain spaces but total root canal filling was evaluated as satisfactory	6.93
Poor obturation	0.50

The authors commented that[10] the general dental practitioners should not extract the tooth or replace a root canal filling material otherwise the patient experiences severe and repeated symptoms. Hence, the result measurements must be related to the patient. They concluded that a complex kind of association among diagnosed pathologies radiographically and subsequently examined judgment by the patients for successful endodontic therapy is required. In our audit cycle, only in 3.96% cases, the tooth was extracted as shown in Table 4. As per the available data from the meta-analysis, authors found four conditions to be significantly improving the tooth survival postendodontic treatment were: (i) postendodontic treatment crown restoration; (ii) tooth having intact proximal contacts (iii); nonabutment tooth for fixed or removable prosthesis; and (iv) tooth, precisely anteriors and premolars.[10]

In our study, we have explored the gaps and practices in the services delivered in endodontic treatment through a clinical audit. A clinical audit in health-care setting enables to explore the problem that has an impact on costs, resources, and risk. It helps in building scientific evidence and provides information on the improvements made on the clinical question, so that it can be easily evaluated. Since the endodontics is a technique sensitive, the training of the staff to set standard should be a requirement. Therefore, the frequency of audit on skills of the staff and current best practice should be evaluated every 6 months. However, every task comes with the challenges and obstacles. In conducting clinical audit, having a clear objective and planning, resources and workload, organizational support, and the most important factors is the lack of interest and unwillingness to change. These obstructing factors can be overcome by having a professional approach toward providing care and setting evidence-based standards in delivering health care. Another possible solution to overcome these barriers is to have a workforce that understands organization health-care goals and objectives.

CONCLUSION

Our study concluded that there is a need of similar audit in endodontic departments where prediction tools are set to know the endodontic treatment outcomes. Similarly, audit should be carried out to determine the change in the practice over a period of time and its impact on the clinical endodontic outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.