Each year NHS Bradford and Airedale organises a peer review process for dentists in the area and following an evaluation of the 08/09 process a decision was made to base the 09/10 peer review on a clinical topic.
After consultation with the clinical advisors, endodontology was chosen as a topic with a focus on clinical audit in order to demystify clinical audit and encourage further improvements in practice. This also gave the opportunity to do an overview of current endodontic practice in Bradford and Airedale and to measure any improvements in best practice and improvements to patient care.
Endodontology is the study of the form, function and health of, injuries to and diseases of the dental pulp and areas around the root of the tooth. It also looks at the prevention and treatment of these, principally infection of the pulp and surrounding areas.
The audit was originally based around the criteria for successful endodontic treatment of teeth based on the European Society of Endodontology quality guidelines, published in 2006. These state that a successful outcome of treatment are based on strict criteria which are; absence of pain, swelling and other symptoms, no sinus tract, no loss of function and radiological evidence of a normal area around the root.
The time frame for inclusion was widened when it became apparent that some practitioners had not been in post for four years so would not have access to this data but the criteria for successful outcome was kept the same. This enabled a larger sample of root treatments to be assessed.
The best practice of endodontics was discussed at meetings on a monthly basis with support from local expert Alyn Morgan, and Paul Brunton, professor and honorary consultant of restorative dentistry at the Leeds Dental Institute.
Of the 232 practitioners registered as performers in Bradford and Airedale, 74 (32 per cent) engaged with peer review for at least one session and 1696 audit forms were collected over the six months.
The outcomes were as follows;
In 79 per cent of cases rubber dam was not used during the root canal procedure. In treatments performed in the last four years, however, rubber dam was not used in only 37 per cent of cases. This shows a significant increase in the more recent treatments. This could be down to better teaching of this technique, younger practitioners being more confident with its use and wider knowledge of dento-legal issues. Rubber dam is important in endodontics to isolate the tooth and prevent further infection of the root canal system from bacteria present in the mouth.
Sodium hypochlorite was the most common irrigant used, in 57 per cent of cases overall. In the last four years 94 per cent of cases used sodium hypochlorite as the irrigant. This increase follows the reasoning behind the increased use of rubber dam. It is worrying that some root canal treatments are being done without rubber dam but with sodium hypochlorite as it is a tissue irritant which should only be placed in the root canal system and not allowed access to other oral tissues. Sodium hypochlorite is important in endodontics as it disinfects the root canal system and dissolves organic material in the system. Research has shown it to be the most effective irrigant.
Ledermix was the most commonly used medicament in 25 per cent of cases. However calcium hydroxide is the most effective medicament and teaching was used to get this across to the group.
Cold lateral condensation is the most common form of obturation. This is regarded as the gold standard although research has shown that the type of obturation used has no effect on the outcome of root canal treatments.
62 per cent of teeth treated were restored with a filling. This goes slightly against the evidence in the literature which shows that back teeth undergoing root canal treatment fare better with a full coverage restoration, such as a crown, but anterior teeth fare better with just a restoration being placed.
89 per cent of teeth treated were still present. This is encouragingly high and compares favourably with other outcome studies which are generally performed in specialist practice or hospital settings. Outcome studies in general practice are rare.
Discomfort and pain were the most common problems mentioned by patients after treatment, occurring in 11 per cent of cases though 67 per cent of patients reported no problems post treatment.
70 per cent of the definitive restorations (this could be a filling or a crown) were still intact which is encouragingly high.
Practitioners who were involved in this process gave excellent feedback with positive comments describing how involvement in this process has helped them change the practice of endodontics and how this allowed them to gain an understanding of the differing techniques across the district in relation to best practice.
Laura Irwin is a quality development facilitator at NHS Bradford and Airedale