This audit system is based on the system developed by Demby, Rosenthal, and Angello as presented in the text entitled “A Comprehensive Quality Assurance System for Practicing Dentists – A Clinical Outcomes Management Approach”. The process for this review is solely through the dental record.

Record Selection

A minimum of five charts should be selected for each dentist to obtain a thorough review of the care provided for different age groups and problems. The standard for selection of these five cases is that the initial phase of treatment has been completed and that services provided are reasonably comprehensive.

Criteria for Record Review

A. Radiographic Assessment

Take out all radiographs taken during the last three years. Evaluate all films for the first four criteria. For the fifth criteria, evaluate only the last set of radiographs.

1. Sufficient Quantity of Films Taken

STANDARDS

Initial Phase
(New Patient)
Recall Phase
Primary Transitional:  2 bitewings  2 bitewings
Second molar unerupted  4 bitewings  4 bitewings
Second molar erupted  4 bitewings  5/30/07> 4 bitewings

This criterion evaluates only the minimum numbers of films that must be taken regardless of the state of the patient’s oral health and is based on the standards promulgated by the Food and Drug Administration. Additional films must be included based on the prevalence and severity of dental disease. In the case of the primary dentition, it may not be necessary to take radiographs in low risk/caries free children. This must be noted in the progress notes.

Check yes if the minimum number of films were taken using the above standards as a guide.
Check no if the standards were not met for at least one phase of treatment.

2. All Film Mounts or Packets Are Dated

Check yes if every mount and packet are dated.
Check no if at least one packet or mount is NOT dated.

3. All Film Mounts and Packets Have A Patient Identification Number

Check yes if every mount and packet have an identification number.
Check no if at least one mount or packet has no identification number.

4. All Film Mounts and Packets Have the Name of the Patient

Check yes if every mount and packet have 5/30/07
Check no if at least one mount or packet has no name of the patient or a name is written illegibly.

5. Quality of Radiographs

Review the radiographs for each of the considerations listed on the audit form. Check problem areas as they apply for the most recent set of radiographs.

Check acceptable if all dental diseases can be diagnosed even with the occurrence of problems.
Check not acceptable if dental disease cannot be diagnosed with the radiographs.

B. Dental Record Assessment

INSTRUCTIONS: Review the dental record for each of the following criteria. First, check each criterion as Present or Absent. Absent data is defined if either the sheet is not included within the record, i.e., it is missing, or if the sheet is present but is not filled out. If the criterion is determined to be absent, go to the next criterion. If the sheet is present, make a determination as to the acceptability of the criterion. Check Acceptable or Not Acceptable using the definition of each criterion presented below.

1. Patient Identification

Check acceptable if the name, address, telephone number, date of birth, and identification number are present in the record
AND
the name or identification number is indicated on each page of the record. 5/30/07the patient data is missing
AND
if the name or identification number is missing on one or more pages of the record.

2. Patient Consent

Check acceptable if the consent is signed and dated by the patient if 18 years or older or by a parent or legal guardian if under 18.
Check not acceptable if the consent is not signed and dated.

3. Medical History

Check acceptable if:

-all boxes on the consent form are checked by the patient AND -the dentist has signed and dated the initial medical history AND -the dentist has indicated review of medical status AND
-a medication profile is included AND
-there is evidence of updating the medical history and medication profile at least at each periodic examination.

Check not acceptable if one or more of the above is not completed.

4. Extraoral/Intraoral Examination

Check acceptable if there is a statement that the area examined is within normal limits or that there is a positive finding. All positive findings should have a written explanation.
Check not acceptable if findings are not recorded or positive findings do not have a written explanation.

5. Dental Charting

Check acceptable if there is notation of caries and missing or exfoliated teeth and that this notation is legible. This notation should also include existing conditions and should be updated at each recall visit.
Check not acceptable if the notation is illegible and is not updated at each recall visit.

6. Problem List/Treatment Plan

Check acceptable if both the problem list and treatment plan are present and both are legible and written as a list.
Check not acceptable if the problem list and/or treatment plan is not present and are not legible or not written as a list.

7. Progress Notes

Check acceptable if all of the following are completed:

  • legibly written notes
  • a date noted for each visit entry
  • procedures performed noted to include a notation of the tooth and surfaces,
  • specific materials (specified by brand or generic names) used for each restoration
  • the type of anesthetic used with the amount in carpules or milliliters
  • specific treatment planned for the next visit
  • radiographs identified by type (bitewings, periapicals) and number
  • prescribed medications with dosage, number, and daily frequency listed
  • signature and degree for each visit.

Check not acceptable if one or more of the following is noted:

  • one or more entries are illegible
  • one or more visits are not dated
  • procedures are incompletely documented
  • the provider’s signature and degree are not written at each visit.

C. Assessment of Treatment

It is this area of the audit that the reviewer has the opportunity to use his/her judgment in reviewing the dental treatment. Each criterion requires several considerations in order to make an assessment of the acceptability of the treatment rendered. Therefore, a list of these pertinent considerations is provided as a guide for making a decision under each criterion on the audit form. Any consideration listed that is not appropriately dealt with by the dentist should be checked in the box adjacent to that consideration. The judgment of the acceptability of each criterion is based largely on the reviewer’s evaluation. At all times, keep in mind whether case management in all its aspects has been appropriately rendered and has met the needs of the patient.

In making your decisions, always ask yourself if the incompleteness of diagnosis, a lack of integration of the non-dental considerations, the inappropriateness of treatment and prevention, and the improper sequence of treatment have had an adverse effect on the oral health status of the patient. If so, then the criterion should be judged as not acceptable. If a problem has not had or may not have an adverse impact on the oral health status of the patient, then the criterion should be judged as acceptable. The key to judging these criteria is the effect of each on the health of the patient, i.e., the outcome of care.

1. Completeness of Diagnosis

Review the record and the radiographs for both clinical findings and treatment provided in the past. Check any consideration listed that was not appropriately diagnosed, either through notation in the record and/or through actual treatment.

To assess the acceptability of the diagnoses made, evaluate the severity of each problem not appropriately diagnosed. Consider whether of not the incompleteness of diagnosis had or may have an adverse effect on the oral health status of the patient; then make a judgment on the acceptability of the diagnosis.

2. Integration of Non-Dental Considerations

In reviewing the record, each of the following four consideration should be assessed:

MEDICAL: Review the medical problems that either alter the course of dental disease and/or impact on the process of dental treatment. Examples of the former include diabetes, HIV infection, blood dyscrasias, Sjogrens syndrome, and hormonal changes. Examples of the latter include rheumatic heart disease, ischemic heart disease, intracardiac prosthesis, asthma, HIV infection, and hepatitis.

EMOTIONAL: Review all psychological problems. Stress and anxiety can decrease salivary flow. Stress may also be a confounding factor in gingivitis, periodontitis, and certain types of stomatitis, as well as an etiological factor in myofascial pain dysfunction. Anxiety and depression can detrimentally affect routine compliance with necessary home preventive care and compliance with routine maintenance professional dental care.

DRUG RELATED: Review all medications currently being taken by the patient. Medications that can affect the course of disease and treatment are Dilantin, calcium channel blockers, tranquilizers, anticoagulants, steroids, aspirin, and anti-cholinergic medications. Also, note drug allergies, chemotherapeutic agents, immunosuppressive agents, medications that can cause severe side-effects, and medications that interfere with the proper development of the dentition such as tetracycline.

LIFESTYLE: Lifestyle has been shown to have a major impact on general health status. In assessing its implication in dentistry, review dietary and nutritional considerations, substance abuse to include smoking, and other areas that make up ones lifestyle.

To make an assessment of this criterion, determine if there were non-dental problems affecting the course of disease and treatment. If there were none, check not applicable. If there were, make a determination as to the effectiveness of the dentist’s treatment regarding these problems. If the dentist either did not consider this problem in the treatment or did not appropriately deal with the problem, both resulting in an unsatisfactory outcome, this criterion should be judged as not acceptable.

3. Appropriateness of Treatment

The appropriateness of care can be defined as the impact of treatment in meeting the needs of the patient. Inappropriate treatment may be defined as wrong for the diagnosis or either too little or too much treatment.

a. Appropriateness of Curative Treatment – Review the radiographs, the problem list, the treatment plan, and the progress notes. Check those services deemed needed but not provided or provided inappropriately on the audit form. Inappropriate is defined as those services provided that are either wrong, too much, or too little for the diagnosis. Examples include extensive restorations for moderate carious lesions, excessive or no periodontal therapy, unwarranted extractions of teeth, inadequate space maintenance in children, and splinting teeth for slight or moderate mobility. Review all services provided and make an assessment of the appropriateness of the treatment provided.

b. Appropriateness of Preventive Care – It is important to remember that caries and periodontal disease are infectious diseases caused by specific bacteria and are responsive to factors that alter the plaque and host resistance. Preventive services work both to prevent disease (primary prevention) and to control disease (secondary prevention). Traditional dental services, particularly restorative services, do not deal with the disease process but tend to restore what was lost to the disease process. Preventive services DO interfere with the disease process and should be an integral part of dental care.

Caries and periodontal disease respond well to specific preventive therapies. Caries can be prevented and controlled through the use of multiple fluoride approaches and through the use of occlusal sealants. Periodontal disease is best prevented and controlled through frequent visits for periodontal scalings and assessments, and oral hygiene reinforcements. If the patient has severe periodontal disease or has a history of frequent flare-ups, the frequency of recall visits is critical to the maintenance of the periodontal status of that patient.

4. Logical Sequence of Treatment

The order in which treatment is completed is a factor in managing dental disease. In general:

  • The first step should be the elimination of disease that is progressing rapidly and/or is threatening the health of the patient and/or is causing pain.
  • The next step is the elimination of non-urgent disease.
  • The final step is the rehabilitation of the mouth to normal function and aesthetics and the establishment of an ongoing maintenance program with periodic and appropriate recall visits.

The sequence of treatment must be in a logical order. Examples of this are the completion of root canal treatment before fabricating a crown; extracting all teeth requiring removal prior to the construction of a removable partial denture; recognizing and treating periodontal disease before placement of complex restorations. To evaluate this criterion, consider if any services planned or provided that deviate from a logical sequence would or have had an adverse impact on the patient.

5. Summary of Case Management

Now, review all your findings and evaluate overall the quality of care given to this patient. Make a final assessment using the ratings of excellent, above standard, adequate, below standard, or substandard.