Lisa McNally Mojtaba Dorri Clinical Audit of the quality of dental screening and preventative management of head and neck oncology patients (DPT, fluoride prescriptions) Re-Audit (CAID 4831) Lisa McNally Mojtaba Dorri

Background  Best practice guidelines (BAHNO, 2009, 2011; RCSEng 2012) on the standards advised for the dental screening process: an OPG radiograph, topical fluorides (such as high concentration toothpaste or mouthrinse) the provision of instruction in oral hygiene measures.  Following the completion of the previous re-audit (2015) a screening proforma was designed and is now in use, in addition to this, the staff members who carry out the screens are at least specialty registrar level, rather than senior house office level, as was the case previously.

Audit Aim Have the dental screenings carried out for head and neck cancer patients met best practice guidelines?

Objectives Was a dental screening performed for all head and neck cancer patients seen as part of the MDT? To assess whether an OPG was taken routinely for all head and neck cancer dental screenings over a recent one-year interval. To assess whether topical fluorides were prescribed for all dentate head and neck cancer patients at their screening appointment.

Standards/Criteria Criteria Target (%) Exceptions Source & Strength* of Evidence 1 All patients seen on MDT should have dental screen 100% None “100% patients should be assessed by a suitably qualified dental practitioner before and after their main treatment” BAHNO (2009) C 2 All Head and Neck cancer patients who received a dental screening should have had an Orthopantomogram performed as part of the diagnostic work up. Diagnosis and Staging- Radiology “OPG for 100% patients (irrespective of primary site)” 3 Daily topical fluoride application (2800ppm or 5000ppm fluoride toothpaste) in custom-made trays or brush-on. OR Daily fluoride mouth rinse. Edentulous patients. “Preventative oral care must be delivered to all patients undergoing treatment for head and neck cancer” BAHNO (2011)   “For patients receiving radiotherapy for head and neck cancer: 100% of dentate patients should be prescribed fluoride mouthwashes” BAHNO (2009) RCS (2012) *Strength of Evidence A At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation B Availability of well-conducted clinical studies but no randomised clinical trials on the topic of the recommendation C Expert committee reports or opinions and/or clinical experience of respected authorities. Absence of directly applicable clinical studies of good quality D Recommended good practice based on clinical experience (local consensus)

Methodology University Hospitals Bristol database representing the period between and inclusive of September 2016 to August 2017 After deduplication, 278 patients Five codes (11 patients) which were deemed “unclear” or not requiring radiotherapy with negative impact on oral health, were excluded  The 147 dental screening forms for the period between and inclusive of September 2016 to August 2017 were audited and compared with the number of head and neck cancer patients who went through MDT clinic (267 patients).

Methodology  Intra-examiner reliability: 20 forms were randomly selected and re-examined after 2 weeks. The intra-examiner kappa value (K = 0.95: 95% CI: − 0.85, 0.98) showed excellent agreement. 120 patients had not been logged onto the dental screening database nor had a photocopy of their dental screening proforma stored in the audit box, suggesting that they had not underwent dental screening. A random sample of 9 patients was selected and their clinical notes were pulled out to identify the likely reasons for missing dental screening.

Results

Number of patients who had a dental screen performed and their forms were stored in the Audit box and logged in the Audit book: 147/267 (55%).

Of 9 randomly selected patients who had no record of dental screening in the Audit box/book: 2 were already being treated by the BDH Oncology Lead Restorative Consultant (LMN); one had been dentally screened but a copy of screening had not been stored in the Audit box; 7 had no records of screening.

Discussions A substantial improvement in the number of Oncology MDT patients who underwent dental screening Still uncompliant with the national guidelines. All members of the Oncology MDT should ensure that all patient receive dental screening. 6.5% of patients did not have an OPG taken. Dental screening team should ensure that all patients have had an OPG radiograph taken All patients received Fluoride toothpaste and mouthwash. The dental screening team should ensure that new staff and trainees are all trained and comply with the national guidelines.

Conclusions Although there has been a substantial improvement in the number of Oncology MDT patients who underwent dental screening, further actions are required to ensure that we fully comply with the national guidelines. Ongoing training for dental screening team to ensure that new staff and trainees are aware and comply with the national guidelines.

Action plan No. Agreed action Implementation date Who is going to do it ? 1 Disseminate results Restorative Audit meeting 07/06/18 SWAG SSG meeting 18/09/18 September 2018 MD, CG 2 Inform MDT that all patients should undergo a dental screen prior to treatment MD 3 Re-audit 18 months February 2019 TBC