1. A Clinical Audit of Dental Trauma Assessment on The Dental Emergency Clinic
Rachel Porter, James R Allison, Emma Beecroft
The results of the audit show that the quality of assessment was variable. Some aspects of the history were recorded very well however others were not. The American Association of Endodontists (AAE) recommend in their trauma guidelines4 that how, when and where the injury occurred, along with the presence of any CNS symptoms such as loss of consciousness or nausea are recorded in the history. The guidelines on avulsed teeth from the British Society of Paediatric Dentistry3 (BSPD) recommend similar, but also that any missing tooth fragments are accounted for. The International Association of Dental Traumatology (IADT) guidelines1, 2 offer no specific advice on history and examination, although they recommend tetanus immunisation status is recorded and a booster given where there has been soil contamination in avulsion injuries. In the present audit, the recording of how and when injuries occurred was good at 100% and 93.1% respectively, but not so good for where (51.5%), whether there was loss of consciousness (51.5%), other injuries (45.5%), tooth fragments (75%) and tetanus status (0%). None of these domains other than how the injury occurred met the standard. Trauma checks were recorded in 93.9% of cases in line with the recommendation of IADT and AAE to perform regular sensibility testing, however this did not meet the standard. A differential diagnosis was recorded in 84.9% of cases and a final diagnosis in only 51.1%, and appropriate treatment plans were present in only 57.6% of cases which all fall below the standard.
The data collected appears to be fairly representative of the injuries seen on the department with a good range of crown, root and periodontal injuries, and most (84.9%) patients were assessed by staff as intended. There were not an excessive number of late presentations which may have otherwise affected the data. The method of data collection, means that by reviewing the appointment book, only cases that were given a review were identified. This means that the most minor of injuries may have been excluded. Similarly where a review was not given, the case would not be identified; it is reasonable to believe that in these cases the assessment may have been worse than those where the clinician appropriately organised a review. This may skew the data in either direction.
It can be assumed that the results obtained were due largely to the practice of the staff assessing. It is likely that so much heterogenicity exists because there are a large number of staff members responsible for assessing patients at different times. In the absence of a well-defined protocol, it is perhaps unsurprising that the assessments differ in quality, and this is likely to occur between staff but also between the patients assessed by one staff member. It would be interesting to see if the quality of assessment improved if there was a more structured system in place on the department for assessment and treatment planning. It is likely that in cases where a diagnosis or full treatment plan was not recoded, the clinician did indeed have a specific plan and diagnosis in mind, but that this was not fully recorded; this is however unacceptable as it is unhelpful for any subsequent clinicians seeing the patient.
Discussion
Introduction
The Dental Emergency Clinic (DEC) exists to manage dental emergencies in patients that do not have access to dental services. Part of this is the treatment of traumatic dental injuries in adult patients (>16 years). Treatment on the clinic is largely provided by undergraduate dental students supervised by various members of staff, however the intention is that treatment of patients presenting with traumatic injuries is carried out by members of staff – usually dental foundation trainees or dental core trainees. At present there is no specific departmental protocol for management of dental trauma on DEC and clinicians are expected to exercise their own clinical judgment in history taking, examination and treatment planning. It is usual for all but the most minor of injuries to have at least one review appointment booked on the clinic.
The aim of the present audit is to ascertain whether the clinical history taking, examination, record keeping and treatment planning for adult patients presenting with dental trauma on DEC is adequate to meet their needs. An external standard was difficult to set, however we expected 100% of cases to have recorded in the clinical notes the elements described in Table 1.
Aims/Standards
Patients were identified retrospectively by reviewing the DEC appointment record book between January and September Records were located for patients who had been given a review appointment for a trauma review. The clinical notes of these identified patients were reviewed and those who had actually suffered dental trauma were identified.
From the notes of each of the trauma patients the age and gender of the patient was recorded and a pro-forma was completed which identified whether the points in Table 1 had been recorded at the initial examination.
Materials and Methods
Category
Assessment Criteria
History
How, when and where the injury occurred, loss of consciousness, other injuries, presence of tooth fragment, tetanus state.
Examination
Were trauma checks recorded?
Diagnosis
Were a provisional and final diagnosis recorded? Where an injury was apparent for the crown, root, and periodontal ligament, had these been recorded?
Treatment plan
Was the treatment plan was deemed “appropriate”?
Treatment provided
Total number of visits to DEC, and whether a splint was placed and the length of splinting in days.
Table 1 – summary of assessment criteria
Changes and Recommendations
Local:
Display audit results locally on DEC and clinical teaching lead to distribute results to all staff.
Develop dental trauma pro-forma assessment sheet to be used on DEC to improve and standardise history taking.
Generate local trauma guidelines to facilitate treatment planning and improve care.
Re-audit to assess impact of these changes.
Directorate:
Share results of audit directorate wide, for wider clinical improvements.
Results
A total of 33 cases were included.
Presentation to DEC
On day of injury: 73% (n=24)
Mean late presentation: 10.5 days
Latest presentation: 36 days
Assessment
84.8% of patients were assessed by staff
Examination
Trauma checks were recorded in 31 cases (93.9%)
Injuries
33 cases had a total of 70 injuries
Mean number of injuries per case: 2.1 (SD: 1.2)
The most injuries sustained in one case was 5
Diagnosis and Treatment
A differential diagnosis was recorded in 85% of cases (n=28)
A final diagnosis was recorded in 52% of cases (n=17)
Mean number of visits – 2.4 (SD 1.03)
References
Andersson L., Andreasen J. O., Day P., Heithersay G., Trope M., Diangelis A. J., et al. (2012). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental traumatology : official publication of International Association for Dental Traumatology. 28:
Diangelis A. J., Andreasen J. O., Ebeleseder K. A., Kenny D. J., Trope M., Sigurdsson A., et al. (2012). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dental traumatology : official publication of International Association for Dental Traumatology. 28: 2-12.
Day PF Gregg TA . Treatment of avulsed permanent teeth in children. Online information available at (Accessed: Nov 2015)
American Association of Endodontists (2014). The Treatment of Traumatic Dental Injuries. AAE: Chicago, IL.
Demographics
Male
73% (n=24)
Mean age (SD)
31 years (16.59)
Age range
61 years (16-77)
Table 2 – summary of demographics