Clinical audit on quality of record keeping of dental implant treatment performed by dental professionals

Aims To evaluate the quality of clinical record keeping for patients who underwent dental implants placement at International Medical University (IMU) Oral Health Centre (OHC).

Materials and methods Quality of record keeping of all dental implants placed in the IMU OHC by dental faculty, dental officers, and postgraduate diploma students between January 2015 to December 2019 was evaluated retrospectively using the electronic records. Interexaminer reliability was evaluated using Fleiss kappa test (κ≥80%). Each parameter was scored if it was recorded or not recorded. Frequency distributions and percentages of each parameter were calculated and tabulated. 

Results The retrospective dental records revealed high accuracy of record keeping in age (99.6%), gender (100%), cone-beam computerised tomography (CBCT) (97.8%), written consent (95.1%), dental implant placement site (94%), implant diameter (93.6%), and implant length (93.4%). Low accuracy of record keeping is shown in smoking (15%), periodontal disease (17.4%), preoperative antibiotics (7.9%), preoperative analgesics (1.9%), preoperative chlorhexidine mouth rinse (7.3%), time of placement (11.4%), countersink drill for dense bone (0.9%), intraoperative radiograph with guide pin to check angulation (19.7%), hydration of bone graft particles (3.6%), ice pack (0%), postoperative chlorhexidine (17.2%), loading protocol (1.8%), disinfection of abutment and restoration (3.9%), and clean-up of residual cement for cement retained prosthesis (14.4%).

Conclusions The clinical record keeping for patients with dental implants placed at IMU OHC was low. Appropriate measures and intervention are to be implemented to enhance the record keeping.