Report of an audit into third molar exodontia D.
1’. Falconer,
E.
E.
Roberts
Department of Oral and Maxiliofacial Surgery, Glan Clwyd Hospital. Bodelwyddan, Dental Research and Inj’ormation Unit, University qf Wales, Bangor.
North Wales, and
A postal audit of the main surgical variables in third molar exodontia under general anaesthesia SUMMARY. was undertaken on consultants holding a National Health contract within the British Isles. This first paper presents the results. A response rate of 175 returned questionnaires from the 247 consultants was obtained (70.9%). Analysis revealed that the majority of consultants use antibiotics, mouthwashes, sutures, analgesics and postoperative review and the minority steroids and per-operative local anaesthetic, routinely in the majority of cases. Approximately half routinely use a chisel as opposed to a bur for bone removal. The consultants who gave all their patients steroids were significantly (~~0.01) more likely to possess a medical qualification than the consultants who did not.
INTRODUCTION Medical audit will play an increasingly important part in the provision of treatment services within the National Health Service (NHS) in the United Kingdom. ‘Working for Patients’ (1080) defined medical audit as ‘the systematic critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the USCof resources and the resulting outcome and quality of life for the patient’. In terms of medical audit, the procedures used in third molar exodontia, within the Hospital Dental Service in the United Kingdom, have never been quantified or reported in a scientific journal. This first paper seeks to correct this deficiency in the literature, by reporting the results of a national survey conducted throughout the United Kingdom.
the patient. In addition, professional data was collected from The Dental Register 1990 and The Medical Register 1090 in relation to all the rcsponding consultants. The data were analyscd by the Dental Kescarch and Information Unit, University of Wales, Bangor, using the computer package SPSS - X. Checks were performed to validate input. The questionnaires were numbered so that the professional data could be compiled with the questionnaire responses. This was done by making a list of the numbers. the names and the professional information and then removing the names and using this second list to add the professional data to the questionnaires. So that at no time was it possible to identify the questionnaire of a particular person or attribute a questionnaire to a particular person.
METHODS
RESULTS
A 22-item questionnaire was sent to the 247 consultant oral and maxillofacial surgeons holding a NHS contract within the United Kingdom. This inquired about their treatment procedures. in the majority of cases, with regard to the removal of third molar teeth. To further standardise the responses a hypothetical case was given of a patient aged 15 to 35 years, who required the removal of a mesioangularly impacted third molar necessitating some bone removal. The procedure to be undertaken under general anaesthcsia on a patient with no relevant medical history and no signs of acute infection. The treatment procedures investigated were: method of bone removal, the USC of antibiotics, steroids, local anaesthctic, sutures. mouth washes. take home analgesics and postoperative rcvicw of
Of the 247 questionnaires that were sent. 175 consultants rcspondcd. giving a response rate of 70.0%. This gave a statistically analysable group: therefore non responders were not sent a second questionnaire. The results are presented under the following headings: i) bone removal, ii) antibiotics. iii) steroids, iv) mouthwashes, v) sutures, vi) local anaesthcsia. vii) take home analgesics, viii) postoperative review and ix) professional data.
i) Bone Removal A bur was used by 78 (44.6%) of the consultants to remove bone, compared with 71 (40.6”L,) who used a chisel and 26 (14.8%) who rcspondcd that they used both routinely (Fig). IS.3
184
British
Journ;rl of Oral
and Xk~xillofxGl
Surscr)
‘penicillin’ or ‘metronidazole’ group dependent on their spectrum of activity. The Table shows that the most commonly used timings arc postoperative only, preoperative with postoperative, and preoperative. pcropcrative with postoperative. There are approximately a quarter of the consultants in each group.
mouthwash
$ 5
review 1 CL
antibiotics
E E ;ii :
analgesics
iii) Steriods steroids
Steroids were given routinely by 57 (32.6%) of the consultants (Fig.). For the majority 49 (86.6%) 01 consultants dcxamcthasone was the preferred drug.
local anaesthetic
96 routinely adopted Figure
- ‘I‘rtxtmcnt
proccdurcs
xioptcd
routinclq
iv) Mouthwushes Mouthwashes were recommended routinely by 160 (91.4%) of the consultants (Fig.). with 144 (90%) recommending the USC of the mouthwash postoperatively. The most commonly recommended one (108 consultants, 67.4%) was a hot salt mouthwash, with 38 (23.8%) recommending a chlorhexidine mouthwash.
Table-‘I’he number of consultantsusing antibiotics qainst drug UKXI and time of administration. Timine .
Antibiotic
Prc-op
Penicillin Mctronidazolc
2 2
3
7 -I’%, A.
Pn-op & Per-op
Mctroniduolc
I
I
O.h’!/u
Prc-op Xr Post-op
Penicillin Metronidazole Penicillin & Metronidazolc ._
-
-
I\;umhcr
_
Total in qoup
_-
42
25 N 9
-
Pre-op & I’cr-op & Post-op
Penicillin Mctronidazolc Penicillin & Mctronidazolc
Per-op
Penicillin klctronidazolc Penicillin & Metronidxolc
2 2 2
Prc &I Post-op
Penicillin Metronidazolc Penicillin & Mctronidazol -.
I6 2 3
Penicillin Mctronidazole Penicillin & Metronidarolc
20 II I4
Post-op
-.
-
v)
-
25.4”/,,
-
40
-
-
27.4””CC1
Sutures
Sutures were used routinely by 172 (98.3%) of the consultants (Fig.). Ninety nine (57.9”/0) were using either plain or chromic soft gut or cat gut, with the majority (60, 35.1%) of the consultants using plain soft gut most frequently. Forth eight (27.4%) were using black silk.
0
vi) Local unaesthesia 6
3.6%
21
12.7’:;
--
-
Percentage of 1otal prcsecribers
--
ii) Antihiorics Antibiotics wcrc given routinely by 134 (76.6%) of the consultants (Fig). Of the 165 consultants who specified the antibiotic they prescribed, 69 (41.8%) used penicillin either as bcnzyl penicillin or phcnoxymcthyl penicillin. Thirty one (18.8%) used metronidazole. 34 (20.6%) used both and 31 (18.8%) used neither. In this latter group the most frequently used antibiotic was ampicillin. The timing of the antibiotic administration can be either preoperative. pcropcrativc. or postoperative or anv of the seven combinations of these. The Table -illustrates the timing of antibiotic administration against the drug used and the number of consultants using it. For the sake of simplification the antibiotics in the ‘other’ group have been redistributed into the appropriate
I_ocal anacsthetic was employed at the time of surgery, together with the general anaesthetic. by 25 (14.3%) of the consultants (Fig.). For 16 (64.0%) of these consultants, the main reason for giving local anacsthetic was postoperative analgesia and for 5 (20%) to reduce arrhythmias. The majority of the consultants (16, 64.0%) who gave local anaesthetic injections at the time of surgery used lignocaine with adrenaline.
vii) Tuke home analgesics After third molar exodontia, the majority of the consultants 123 (70.3%) prescribed take home analgesics as a routine, with 109 (62.3%) of the responding consultants specifying their take home analgesic of choice. Thirteen different drugs were being prescribed. Grouping these drugs together it was found that 34 (31.2%) were prescribing paracetamol and codeine mixture with or without caffeine, 25 (22.9%) paracctamol alone and 20 (18.3%) non-steroidal anti-inflammatory drugs, and 30.(27.5%) were using the remaining five analgesics.
viii) Postoperative review After surgery. 150 (85.7%) reviewed their uncomplicated (Fig.).
of the consultants cases as out-patients
Report
ix) Professional duta In relation to the audit no significant differences were found in terms of when the consultant graduated in dentistry, or whether they possessed a medical qualification or not, other than in the question of steroid treatment. 01’the I75 consultants involved in the audit, X6 (49.1%) had both a medical and dental qualification. A significant difference was found between consultants who were medically qualified and those who were not in relation to whether they routinely gave all their patients steroids. 01’ the 57 consultants who routinely gave steroids. 37 (64.0%) were medically qualified (p. Farrclly. Research Assistant. Clwyd Health Authority: Dr G IIumphris. Senior Rcscarch Fellow. Dental Research and Information Unit: and Professor Lowe. University of Wales. Bangor for his active support of dental research. The authors gratefully acknowledge the financial support of the Clwyd Institute of Health Studies Joint Research Committee.
Reference DISCL!SSION The present audit of consultants’ treatment procedures in third molar exodontia cases indicates that the majority employ antibiotics, mouthwashes. sutures, analgesics and review, and the minority steroids and pcroperativc local anaesthetics. The consultants wcrc approximately equally divided between their use of chisels or burs in bone removal. These findings revealed considerable variation in the treatment procedures adopted by the individual consultants. It is likely that this variation results from a multiplicity of factors including: the influence of the consultant’s own training, junior staff training requirements, perceived patient benefits and the influence of published articles in scientific journals. In a future paper it is intended to review the litcraturc to assess the support this gives for thcsc treatment proccdurcs. Finally it is suggested that the data provided in this
for Patients’ (1989). MdicalAudi/ NHS Rni~w. Working Puper6. Department of Health. London: Her
‘Working
Maiesty’s
Stationcry
Office.
The Authors I).‘I‘.Falconer HChD, MHChB, FDSRCS. FRCS Registrar in Oral and Maxillofacial Glan Clwyd Ilospital. Bodclwyddcn. Rhyl. Clwyd. I.Ll8ilJJ
Surgery.
E. E. Roberts PhD, MDS, MCDH, DOrth, DDPH, LDS, LHSM Director. Dental Rcscarch and Information Unit. Department of Psychology. University of W&s. Bangor. Gwyncdd I.157 2D
1’. Falconer,
E.
E.
Roberts
Department of Oral and Maxiliofacial Surgery, Glan Clwyd Hospital. Bodelwyddan, Dental Research and Inj’ormation Unit, University qf Wales, Bangor.
North Wales, and
A postal audit of the main surgical variables in third molar exodontia under general anaesthesia SUMMARY. was undertaken on consultants holding a National Health contract within the British Isles. This first paper presents the results. A response rate of 175 returned questionnaires from the 247 consultants was obtained (70.9%). Analysis revealed that the majority of consultants use antibiotics, mouthwashes, sutures, analgesics and postoperative review and the minority steroids and per-operative local anaesthetic, routinely in the majority of cases. Approximately half routinely use a chisel as opposed to a bur for bone removal. The consultants who gave all their patients steroids were significantly (~~0.01) more likely to possess a medical qualification than the consultants who did not.
INTRODUCTION Medical audit will play an increasingly important part in the provision of treatment services within the National Health Service (NHS) in the United Kingdom. ‘Working for Patients’ (1080) defined medical audit as ‘the systematic critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the USCof resources and the resulting outcome and quality of life for the patient’. In terms of medical audit, the procedures used in third molar exodontia, within the Hospital Dental Service in the United Kingdom, have never been quantified or reported in a scientific journal. This first paper seeks to correct this deficiency in the literature, by reporting the results of a national survey conducted throughout the United Kingdom.
the patient. In addition, professional data was collected from The Dental Register 1990 and The Medical Register 1090 in relation to all the rcsponding consultants. The data were analyscd by the Dental Kescarch and Information Unit, University of Wales, Bangor, using the computer package SPSS - X. Checks were performed to validate input. The questionnaires were numbered so that the professional data could be compiled with the questionnaire responses. This was done by making a list of the numbers. the names and the professional information and then removing the names and using this second list to add the professional data to the questionnaires. So that at no time was it possible to identify the questionnaire of a particular person or attribute a questionnaire to a particular person.
METHODS
RESULTS
A 22-item questionnaire was sent to the 247 consultant oral and maxillofacial surgeons holding a NHS contract within the United Kingdom. This inquired about their treatment procedures. in the majority of cases, with regard to the removal of third molar teeth. To further standardise the responses a hypothetical case was given of a patient aged 15 to 35 years, who required the removal of a mesioangularly impacted third molar necessitating some bone removal. The procedure to be undertaken under general anaesthcsia on a patient with no relevant medical history and no signs of acute infection. The treatment procedures investigated were: method of bone removal, the USC of antibiotics, steroids, local anaesthctic, sutures. mouth washes. take home analgesics and postoperative rcvicw of
Of the 247 questionnaires that were sent. 175 consultants rcspondcd. giving a response rate of 70.0%. This gave a statistically analysable group: therefore non responders were not sent a second questionnaire. The results are presented under the following headings: i) bone removal, ii) antibiotics. iii) steroids, iv) mouthwashes, v) sutures, vi) local anaesthcsia. vii) take home analgesics, viii) postoperative review and ix) professional data.
i) Bone Removal A bur was used by 78 (44.6%) of the consultants to remove bone, compared with 71 (40.6”L,) who used a chisel and 26 (14.8%) who rcspondcd that they used both routinely (Fig). IS.3
184
British
Journ;rl of Oral
and Xk~xillofxGl
Surscr)
‘penicillin’ or ‘metronidazole’ group dependent on their spectrum of activity. The Table shows that the most commonly used timings arc postoperative only, preoperative with postoperative, and preoperative. pcropcrative with postoperative. There are approximately a quarter of the consultants in each group.
mouthwash
$ 5
review 1 CL
antibiotics
E E ;ii :
analgesics
iii) Steriods steroids
Steroids were given routinely by 57 (32.6%) of the consultants (Fig.). For the majority 49 (86.6%) 01 consultants dcxamcthasone was the preferred drug.
local anaesthetic
96 routinely adopted Figure
- ‘I‘rtxtmcnt
proccdurcs
xioptcd
routinclq
iv) Mouthwushes Mouthwashes were recommended routinely by 160 (91.4%) of the consultants (Fig.). with 144 (90%) recommending the USC of the mouthwash postoperatively. The most commonly recommended one (108 consultants, 67.4%) was a hot salt mouthwash, with 38 (23.8%) recommending a chlorhexidine mouthwash.
Table-‘I’he number of consultantsusing antibiotics qainst drug UKXI and time of administration. Timine .
Antibiotic
Prc-op
Penicillin Mctronidazolc
2 2
3
7 -I’%, A.
Pn-op & Per-op
Mctroniduolc
I
I
O.h’!/u
Prc-op Xr Post-op
Penicillin Metronidazole Penicillin & Metronidazolc ._
-
-
I\;umhcr
_
Total in qoup
_-
42
25 N 9
-
Pre-op & I’cr-op & Post-op
Penicillin Mctronidazolc Penicillin & Mctronidazolc
Per-op
Penicillin klctronidazolc Penicillin & Metronidxolc
2 2 2
Prc &I Post-op
Penicillin Metronidazolc Penicillin & Mctronidazol -.
I6 2 3
Penicillin Mctronidazole Penicillin & Metronidarolc
20 II I4
Post-op
-.
-
v)
-
25.4”/,,
-
40
-
-
27.4””CC1
Sutures
Sutures were used routinely by 172 (98.3%) of the consultants (Fig.). Ninety nine (57.9”/0) were using either plain or chromic soft gut or cat gut, with the majority (60, 35.1%) of the consultants using plain soft gut most frequently. Forth eight (27.4%) were using black silk.
0
vi) Local unaesthesia 6
3.6%
21
12.7’:;
--
-
Percentage of 1otal prcsecribers
--
ii) Antihiorics Antibiotics wcrc given routinely by 134 (76.6%) of the consultants (Fig). Of the 165 consultants who specified the antibiotic they prescribed, 69 (41.8%) used penicillin either as bcnzyl penicillin or phcnoxymcthyl penicillin. Thirty one (18.8%) used metronidazole. 34 (20.6%) used both and 31 (18.8%) used neither. In this latter group the most frequently used antibiotic was ampicillin. The timing of the antibiotic administration can be either preoperative. pcropcrativc. or postoperative or anv of the seven combinations of these. The Table -illustrates the timing of antibiotic administration against the drug used and the number of consultants using it. For the sake of simplification the antibiotics in the ‘other’ group have been redistributed into the appropriate
I_ocal anacsthetic was employed at the time of surgery, together with the general anaesthetic. by 25 (14.3%) of the consultants (Fig.). For 16 (64.0%) of these consultants, the main reason for giving local anacsthetic was postoperative analgesia and for 5 (20%) to reduce arrhythmias. The majority of the consultants (16, 64.0%) who gave local anaesthetic injections at the time of surgery used lignocaine with adrenaline.
vii) Tuke home analgesics After third molar exodontia, the majority of the consultants 123 (70.3%) prescribed take home analgesics as a routine, with 109 (62.3%) of the responding consultants specifying their take home analgesic of choice. Thirteen different drugs were being prescribed. Grouping these drugs together it was found that 34 (31.2%) were prescribing paracetamol and codeine mixture with or without caffeine, 25 (22.9%) paracctamol alone and 20 (18.3%) non-steroidal anti-inflammatory drugs, and 30.(27.5%) were using the remaining five analgesics.
viii) Postoperative review After surgery. 150 (85.7%) reviewed their uncomplicated (Fig.).
of the consultants cases as out-patients
Report
ix) Professional duta In relation to the audit no significant differences were found in terms of when the consultant graduated in dentistry, or whether they possessed a medical qualification or not, other than in the question of steroid treatment. 01’the I75 consultants involved in the audit, X6 (49.1%) had both a medical and dental qualification. A significant difference was found between consultants who were medically qualified and those who were not in relation to whether they routinely gave all their patients steroids. 01’ the 57 consultants who routinely gave steroids. 37 (64.0%) were medically qualified (p. Farrclly. Research Assistant. Clwyd Health Authority: Dr G IIumphris. Senior Rcscarch Fellow. Dental Research and Information Unit: and Professor Lowe. University of Wales. Bangor for his active support of dental research. The authors gratefully acknowledge the financial support of the Clwyd Institute of Health Studies Joint Research Committee.
Reference DISCL!SSION The present audit of consultants’ treatment procedures in third molar exodontia cases indicates that the majority employ antibiotics, mouthwashes. sutures, analgesics and review, and the minority steroids and pcroperativc local anaesthetics. The consultants wcrc approximately equally divided between their use of chisels or burs in bone removal. These findings revealed considerable variation in the treatment procedures adopted by the individual consultants. It is likely that this variation results from a multiplicity of factors including: the influence of the consultant’s own training, junior staff training requirements, perceived patient benefits and the influence of published articles in scientific journals. In a future paper it is intended to review the litcraturc to assess the support this gives for thcsc treatment proccdurcs. Finally it is suggested that the data provided in this
for Patients’ (1989). MdicalAudi/ NHS Rni~w. Working Puper6. Department of Health. London: Her
‘Working
Maiesty’s
Stationcry
Office.
The Authors I).‘I‘.Falconer HChD, MHChB, FDSRCS. FRCS Registrar in Oral and Maxillofacial Glan Clwyd Ilospital. Bodclwyddcn. Rhyl. Clwyd. I.Ll8ilJJ
Surgery.
E. E. Roberts PhD, MDS, MCDH, DOrth, DDPH, LDS, LHSM Director. Dental Rcscarch and Information Unit. Department of Psychology. University of W&s. Bangor. Gwyncdd I.157 2D
