December issue.indd

An audit of the implementation of guidelines in relation to the prevention of dental caries

J. Foley
Department of Paediatric Dentistry, Dundee Dental Hospital, Dundee, DD1 4HN, U.K.

Correspondence to: J. Foley, Unit of Dental and Oral Health, Dundee Dental Hospital, Dundee, DD1 4HN, U.K. Email: jennifer.i.foley@tuht.scot.nhs.uk

Keywords: Clinical guidelines, prevention, dental caries, audit
Surg J R Coll Surg Edinb Irel., 1 December 2003, 350-353

Aim: To determine the implementation of national clinical guidelines in relation to the targeted prevention of dental caries in the permanent teeth of 6-16-year-olds presenting for dental care amongst training grade staff working within the Hospital Dental Service. Methods: Patient records were reviewed prospectively with regard to caries risk assessment, behaviour modification and tooth protection. Following dissemination of the results and reinforcement of fundamental points from the guideline, a second audit was conducted one month later. The results were assessed by chi2 (X²) analysis. Results: One hundred patient records were reviewed in both Audit One (M:52; F:48) and Audit Two (M:61; F:39). Caries risk assessment was poorly recorded in both Audits One and Two (13% and 17%, respectively). There was an improvement in radiographic reporting between the first and second audit, from 53% to 80% (.2 = 16.36, P = 0.001). Dietary advice and toothbrushing instruction were recorded in 36% and 41% of records in Audit One, whilst in Audit Two this had improved to 68% and 92%, respectively (X² = 20.51, P = 0.001 and X² = 58.38, P = 0.001). There was a statistically significant improvement in the prescription of fissure sealants in Audit Two (X² = 38.97, P = 0.001), although not in the prescription of topical fluoride application (X² = 1.71, P = 0.192). Conclusion: Amongst training grade staff, there appears to be failure of implementation of certain aspects of SIGN guidelines for caries prevention. Clinical audit, however, would appear to improve guideline implementation

INTRODUCTION
Dental caries in permanent teeth is a major health problem in Scotland, with 68% of 14-year-olds having some evidence of dental caries.¹ Furthermore, the prevalence of caries is markedly skewed, with 6% of 14-year-olds experiencing 50% of untreated caries.¹ The publication in December 2000 of the 47th SIGN Guideline, Preventing dental caries in children at high caries risk: Targeted prevention of dental caries in the permanent teeth of 6-16 year olds, was an acknowledgment of the scale and skewed nature of the disease. Also, recognition of the significant variation in the type of dental care provided, reflecting the uncertainty within the profession as to which preventive régimens are most effective.² There are, however, proven, effective preventive techniques agreed upon in the SIGN guideline that can be targeted to help those at greatest risk of dental caries. In order to deliver effective prevention, accurate, early diagnosis is important; dental radiography is an essential adjunct to clinical examination.³ Having identified high caries risk individuals,measures to prevent caries include a reduction in the frequency of sugar consumption, twicedaily toothbrushing with a fluoride toothpaste and the use of tooth-protective agents such as topical fluoride varnishes and fissure sealants.^4-7 Successful implementation of the preventive régimens in the guideline should contribute to a lower prevalence of dental caries, lower the cost of treating dental caries (e.g. in 1997/98 the cost to NHS General Dental Services of amalgam [silver] fillings alone was £2.3 million for Scottish 0-17-yearolds) and avoid the repetitive, costly, lifelong cycle of repeated restoration that is seen once an initial filling is placed.^8,9 The aim of this audit was to determine the implementation of national clinical guidelines amongst training grade staff working within the Hospital Dental Service in relation to the targeted prevention of dental caries in the permanent teeth of 6-16-year-olds presenting for dental care.

Audit one
Patient records of both new referral and casual patients diagnosed with dental caries and seen by four training grade staff working within the Department of Paediatric Dentistry at Edinburgh Dental Institute, Lothian Primary Care Trust during 2002-2003, were reviewed prospectively according to the following essential points identified from the SIGN guideline.

• Was there an assessment in writing of the patient’s caries risk status?

• Was specific dietary advice identified in the notes, e.g. reduction in the frequency of consumption of sugary foods and ‘safe drinks’ such as milk and water?

• Was specific toothbrushing advice mentioned, e.g. twice daily brushing, using toothpaste containing at least 1000ppm fluoride and ‘spit don’t rinse’ at the end of brushing?

Audit two
Results from Audit One were disseminated amongst the four clinicians along with reinforcement of the key points from the guidelines. Following a one month period, a further 100 patient records (of the same clinicians) were reviewed according to the above parameters.

Audit one
One hundred sets of patient records were reviewed in Audit One (M:52; F:48) with a mean age at presentation of 9.4 years (range: 6.2-15.7). Mention of the patient’s caries risk was noted in 13% of patient records. Radiographs were prescribed in 87% of cases, with radiographs reported upon in 53% of cases. Dietary advice was noted in 36% of records, with 12% of these mentioning specific preventive dietary recommendations. Fluoride advice in relation to toothbrushing was mentioned in 41% of cases, with specific recommendations documented in 18% of records. Prescription of fissure sealants and fluoride varnish were recorded in 32% and 9% of patient notes, respectively (Table 1).

Audit two
A further 100 patient records were reviewed in Audit Two (M: 61; F:39) with the mean age at presentation being 10.8 years (range: 6.5-14.9). There was no significant increase in the documentation of patient caries risk status, recorded in 17% of notes. Radiographic exposures were undertaken in 92% of cases with a radiographic report completed in 80% of notes, significantly more than in Audit One. Dietary advice was mentioned in 68% of patient records; specific dietary recommendations, however, were mentioned in only 21% of cases. There was a significant improvement in both toothbrushing and specific toothbrushing advice that was noted in 92% and 39% of records, respectively. Fissure sealants and fluoride varnish were observed in 76% (a significant improvement on Audit One) and 15% of patient case notes, respectively (Table 1).

DISCUSSION
Publication of the 47th SIGN guideline specifically for the prevention of dental caries in high caries risk children represents national efforts to promote reliable standards of high quality evidence-based preventive dental care and is consistent with the policies and priorities of the Scottish Executive.¹⁰ The present audit was designed to investigate the implementation of this nationally agreed guideline amongst training grade staff working within the Hospital Dental Service. Although the sample size was relatively small, the initial audit would appear to give a reasonable representation of adherence to the guideline with the subsequent audit demonstrating an improvement in relation to certain aspects of the guideline document following dissemination of the results of the initial audit. Previous authors have also confirmed progressive improvement in relation to adherence with SIGN guidelines as well as an improvement in relation to clinical documentation following presentation of the results of an audit of clinical records.¹¹ Other workers have even gone as far as to suggest that without clinical audit, guideline implementation is unlikely to succeed.¹²

The concept of caries risk assessment is essential to the implementation of the guidelines. For individual patients, risk assessment relates to both objective indicators, such as clinical evidence of previous disease, the patient’s dietary habits and medical history, as well as the dentist’s subjective clinical judgment.^13-15 Within this study, accurate recording of a patient’s caries risk status was poorly recorded for both Audit One and Audit Two. Fundamental to the caries risk assessment process, however, is accurate caries diagnosis with radiographic examination being an essential adjunct to clinical examination.³

It is important to note that within Audit One and Audit Two, 87% and 92% of patients had diagnostic radiographs taken and as such, it would be fair to assume that the study clinicians were aware of the high caries risk status of their patients, although they were presumably failing to document their risk assessment status within patient records. Other studies have also demonstrated such poor documentation of essential aspects of patient care, followed by progressive improvement in record keeping subsequent to audit of clinical practice.¹¹ Despite the notable use of radiography recorded in both audits, in just over 50% of cases in Audit One was a radiographic report recorded within patient records. Although this total had increased in Audit Two, there was still a proportion of patients for whom no report on radiographic findings were made. Nonreporting or delayed reporting of plain radiographs has been observed in other studies. Indeed, in one questionnaire survey of radiographic reporting amongst consultant radiologists based within UK hospitals, in only 16% of cases were all films reported upon. Interestingly, dental films were identified as radiographs not reported upon with the commonest reason for non-reporting being the belief that the report would not influence clinical management.¹⁶

Regarding behaviour modification, there was a significant improvement in relation to the documentation of dietary advice and toothbrushing advice; there was, however, a disappointing improvement in the documentation of specific dietary and toothbrushing recommendations. The evidence that sugar causes dental caries is conclusive with the basic observation that increasing the frequency of sugar intake increases the risk of developing dental caries; conversely reducing the frequency of sugar consumption, reduces the risk.⁴ As such, SIGN guideline advice to patients is to reduce the quantity and frequency of sugar intake, particularly avoidance of sugar intake between meals and at bedtime. Regarding toothbrushing advice, the SIGN guideline document recommends that children should brush their teeth twice per day, using a toothpaste containing at least 1000 parts per million (ppm), spitting out the toothpaste after brushing rather than rinsing with water.¹⁷ In relation to the present study, in many cases, detailed dietary and toothbrushing advice was almost certainly being imparted at the chair-side whilst undertaking other dental procedures or even administrative tasks; presumably, however, such recommendations were not being recorded in the notes. Furthermore, a significant proportion of patients were referred to the Hospital Dental Service by local general dental practitioners and as such, the receiving clinicians may have assumed that specific preventive advice had previously been imparted by the patient’s local dentist.

In relation to tooth protection, there was an improvement in relation to the prescription of fissure sealants between the first and second audit but not, however, the prescription of fluoride varnish. Evidence-based preventive advice within the SIGN guidelines advocates that fissure sealants should be applied and maintained in the tooth pits and fissures of high caries risk children and that professional application of fluoride varnish should be undertaken every four to six months.^6,18 Regarding the prescription of fissure sealants, this would appear to be less than optimal in both audits. In a proportion of cases, however, this may have been due to the fact that the permanent molars had already been fissure sealed or even that these teeth had been extracted as part of an overall treatment plan. The reasons for the disappointingly poor prescription of fluoride varnish are unknown. Other studies have also demonstrated a limited consideration of the use of fluoride varnish.¹⁹ Again, in the present audit, it may be assumed that the receiving clinicians considered that the long-term preventive care of these patients was the responsibility of the referring dental practitioner. Furthermore, other studies have demonstrated that compliance with guideline recommendations may vary depending upon the clinician’s normal practice.²⁰

CONCLUSION
The present study has demonstrated that amongst training grade staff, there appears to be inadequacies in relation to the implementation of certain aspects of the SIGN guidelines, possibly due to failure of documentation or lack of staff compliance. Clinical audit would appear to be imperative if guideline implementation is to succeed.

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17. Report of the Consultants in Dental Public Health. The use of fluoride toothpaste and toothpaste supplements in Scotland. 1998.
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TABLE 1. SUMMARY OF THE PROPORTION OF OBSERVATIONS RECORDED FOR AUDIT ONE AND AUDIT TWO
	Audit one (%)	Audit two (%)	X²	P
Caries risk recorded	13	17	0.63	0.428
Radiographs taken	87	92	1.33	0.249
Radiographic report	53	80	16.36	0.001
Diet advice recorded	36	68	20.51	0.001
Specific diet advice	12	21	2.94	0.086
Toothbrushing recorded	41	92	58.38	0.001
Specific toothbrushing advice	18	39	10.82	0.001
Fissure sealants prescribed	32	76	38.97	0.001
Fluoride varnish prescribed	9	15	1.71	0.192