Clinical Audit Report: Are children having the

recommended recall bitewings taken according to

their caries risk?

1. Background
Bitewing radiographs are a quick, simple, and helpful method of investigation typically
carried out during recall and examination appointments. They serve a crucial role in
identifying areas of decay that are clinically difficult to visualize, such as interproximal
cariesi. Additionally, bitewings can reveal early signs of gum disease and the
development of underlying dentition in children. The frequency of bitewing radiographs
is determined by the patient's caries risk, which is categorized as low, medium, or high
based on specific parameters, including the presence of new or active lesions. This risk is
reassessed at follow-up appointments and provides significant information about the
progression of a lesion over time.

Although clinicians understand the importance of routine bitewings, they may sometimes
forget or assume that, in the absence of clinical pathology during intra-oral exams,
bitewings are unnecessary. However, it is crucial to recognize that deciduous teeth are
more vulnerable to faster progressions of decay compared to adult dentition. Therefore,
routine bitewing radiographs in children are essential in identifying decay at an early
stage and preventing premature tooth lossii. Losing primary teeth prematurely can have
significant impacts on the child's dentition as they grow older.

In addition to detecting decay, bitewings can also help monitor the progression of a
child's permanent dentition. This monitoring is particularly important as it can identify
whether referrals for orthodontic treatment are necessaryiii. Therefore, bitewings play a
critical role in routine dental care for children as they can help prevent significant oral
health problems in the future.

2. Aim and objectives

2.1 To carry out an audit on whether clinicians are carrying out regular bitewings
based on the patient caries risk
2.2 Objectives
 To determine whether regular bitewing radiographs are being taken on
children based on their caries rate in accordance with established
guidelines and standards.
 To identify barriers to the implementation of regular bitewing
radiographs based on a child's caries rate.

3. Audit standards
3.1 The criteria will be set against the FGDP guidelines published in Selection
Criteria for Dental Radiography updated 2018iv
 High risk: It is recommended that all children at high caries risk have six
monthly posterior bitewing radiographs taken until no new or active
lesions are apparent and the individual has entered another risk category
  Moderate risk: It is recommended that all children with a moderate risk of
developing caries have annual posterior bitewing radiographs taken
until no new or active lesions are apparent and the patient has entered
another risk category
 Low risk: It is recommended that children with low caries risk should be
radiographed at approximately 12 to 18-month intervals in the primary
dentition and at approximately two-year intervals in the permanent
dentition. More extended radiographic recall intervals may be appropriate
if there is specific evidence of continuing low caries risk.
3.2 The target is 70%, this is an achievable target, since there are certain
considerations that have to be considered such as time pressure in the NHS, as
well as the co-operation of the child and children that are below the age of 5
that are not suitable for bitewing radiographs

FIRST CYCLE
4. Methodology
4.1 Data Collection: Data will be collected over a one-month period. Data
collection for the first cycle will be carried out in the month of October
4.2 Data will be collected from the R4 clinical software, every dentist that has
seen a child patient will have their caries risk status assessed and seen whether
routine radiographs match with the childs caries risk. Data will be collected
and presented on a spreadsheet.
4.3 The aim is to have at least 100 samples of patient data, Ages: 6-18
4.4 Audit period: October 2022 - Jan 2023

5. Results
- Total number of patients in the first cycle: 158
o High risk: 41 patients
o Mod risk: 29 patients
o Low risk: 88 patients
- Number of participants that were too young to have bitewings taken: 18
- True number of participants: 140
Total number of patients with routine bitewings being taken at recall
appointments: 49 (35%)
o High risk – 46.3% (19/41)
o Mod risk – 27.6% (8/29)
o Low risk –25% (22/88)
- Total number of patients that do not have their routine bitewings taken at
recall appointments: 90 (65%)
o High risk – 56.4% (22/41)
o Mod risk – 72.4% (21/29)
o Low risk – 75% (66/88)
 The difference between taking routine bitewings
for all caries risk children patients

Taking routine BW Not taking routine Bitewings

Figure 1: Pie chart representing percentage of child patients having their bitewings taken routinely versus not having them
taken routinely – first cycle

Different Risk Categories

Number of low risk

Number of mod risk

Number of high risk

0 10 20 30 40 50 60 70 80 90 100
Number of patients

No Yes Total
Figure 2: Bar chart representing different categories of risk status, the total number of patients in each category and how
many of those have bitewings taken routinely – first cycle

6. Conclusion and Changes

Based on the audit findings, it is evident that there is a significant disparity between the
recommended practice of conducting routine bitewing radiographs on children based on
their caries risk and the actual practice in our clinical setting. The results indicate that
only 35% of patients are receiving routine bitewings according to their caries risk, leaving
the remaining 65% without this important examination component. Furthermore, it was
discovered that over 50% of children at high risk for caries are not receiving routine
bitewings, which could lead to more complex treatments in the future and an increased
likelihood of patients returning in pain due to undetected carious lesions.
 To address this gap and enhance the quality of care provided to our patients, I initiated
several interventions. First, I communicated with all clinicians and nurses through our
internal messaging service by R4 to emphasize the importance of adhering to the
recommended practice of taking routine bitewing radiographs based on caries risk.

Additionally, I created a color-coded sheet that aligns with the FGDP guidelines, serving
as a reference tool for clinicians. This sheet allows them to easily cross-reference the
patient's caries risk with the date of the last radiograph, providing a prompt to consider
additional bitewings at the recall appointment (refer to figure 3). These interventions aim
to increase the percentage of patients receiving routine bitewing radiographs according to
their caries risk and ensure adherence to established guidelines and standards.

During the implementation process, we received feedback from clinicians highlighting

child cooperation as a significant challenge in conducting bitewing radiographs. They
also expressed concerns about compliance and difficulty fitting the bitewing holder in
some children's mouths. To address this issue, we have requested that the head nurse
procure a supply of self-adhesive bitewing tabs. These tabs will make it easier for
clinicians to take radiographs without causing discomfort to the child.

In conclusion, this audit underscores the need for continuous monitoring and evaluation
of our practice to ensure the provision of the highest quality of care to our patients. By
implementing the recommended interventions, we can enhance the quality of care
delivered to children in our clinical setting and promote better oral health outcomes.
Regular monitoring and evaluation, along with ongoing training and support, will
contribute to the sustained improvement of our practice and the overall well-being of our
patients.

Figure 3: Easy to follow guideline

2nd CYCLE

1. Methodology
1.1 Data Collection: Data will be collected over a one-month period similar to the
first cycle. Data collection for the second cycle will be carried out in the
month of January
1.2 Data will be collected from the R4 clinical software, every dentist that has
seen a child patient will have their caries risk status assessed and seen whether
routine radiographs match with the child’s caries risk.
 Data will be collected and presented on a spreadsheet.
1.3 The aim is to have at least 100 samples of patient data

2. Results
- Total number of patients in the second cycle: 134
o High risk: 56 patients
o Mod risk: 32 patients
o Low risk: 46 patients
- No data was collected from patients that were too young to receive
bitewings
Total number of patients with routine bitewings being taken at recall
appointments: 82 (61%)
o High risk – 64 % (36/56)
o Mod risk – 53.1% (17/32)
o Low risk –63% (29/46)
- Total number of patients that do not have their routine bitewings taken at
recall appointments: 52 (39%)
o High risk – 35.7% (20/56)
o Mod risk – 46.9% (15/32)
o Low risk – 37% (17/46)

The difference between taking routine bitew-

ings for all caries risk children patients

Taking routine BW Not taking routine Bitewings

Figure 4: Pie chart representing percentage of child patients having their bitewings taken routinely versus not having them

taken routinely – second cycle

 Different Risk Categories
Number of low risk

Number of mod risk

Number of high risk

0 10 20 30 40 50 60
Number of patients

No Yes Total

Figure 5: Bar chart representing different categories of risk status, the total number of patients in each category and how
many of those have bitewings taken routinely – second cycle

3. Discussion
After the second cycle of the audit, it is evident that some of the interventions
implemented have had a positive impact on the number of routine bitewings being
performed on children. To ensure accurate data, I examined a similar-sized cohort of
child patients over the month of January. Overall, the percentage of children receiving
bitewings based on their risk status increased from 35% to 61%. The percentage of
children not having routine bitewings taken at their recall after the second cycle
decreased to 39%, compared to 65% in the first cycle. Although I did not meet the
audit standards by just under 10%, the overall improvement demonstrates that the
interventions implemented in the first cycle were gradually successful in increasing
routine bitewings in children.

In the high-risk category, 64% of children were now receiving routine bitewings,
compared to 46% in the first cycle. The color-coded sheet was helpful in allowing me
to determine when the last bitewing was taken and guide me on whether I needed to
take a bitewing based on other factors during the examination. I also included the
sheet in the practice's Z drive for future use, as per my Educational Supervisor's
guidance.

Patient compliance was an obstacle mentioned by myself and other clinicians. The
adhesive bitewing tabs proved to be more comfortable, and I used them as a tool to
improve patient compliance. They were easier to use than large bitewing holders for
adults and older children. However, some clinicians preferred to use the original
bitewing holders and mentioned that they were unsure or forgot how to use the
adhesive tabs. To address this, I believe printing a page with instructions, in addition
to the color-coded sheet, may encourage clinicians to use the tabs more frequently.
Another obstacle I identified as I saw more patients was the issue of time. Child
patient examinations were limited to 15 minutes, and for other clinicians, it may be as
short as 10 minutes. I suggest discussing this topic in a future group tutorial or
meeting to brainstorm ways to balance time constraints while still providing
comprehensive care.
 Overall, the second cycle of the audit shows improvement in the percentage of
children receiving routine bitewings based on their risk status. With ongoing
monitoring and further refinement of interventions, we can continue to enhance the
quality of care provided to children in our clinical setting. Collaboration and sharing
best practices among clinicians will also contribute to better patient outcomes.

4. Final reflection
This audit is significant because improving the quality of care for children has a
positive impact on their oral health outcomes. Through the implementation of
evidence-based interventions, we can enhance preventive measures, promote early
detection and intervention, and optimize treatment outcomes. These efforts ultimately
contribute to better oral health and overall well-being among our young patients. The
audit has heightened my awareness of the importance of early detection in children
and the value of radiography as a vital diagnostic tool in this population. It is essential
not to underestimate the role of radiography as a means of investigation in children.

I intend to conduct a similar audit in the future, and with more time and additional
cycles, my aim is to surpass the given target.
i
García-Cañas Á, Bonfanti-Gris M, Paraíso-Medina S, Martínez-Rus F, Pradíes G. Diagnosis of
Interproximal Caries Lesions in Bitewing Radiographs Using a Deep Convolutional Neural
Network-Based Software. Caries Res. 2022;56(5-6):503-511. doi: 10.1159/000527491. Epub 2022
Nov 1. PMID: 36318884.
ii
Vieira AR, Gibson CW, Deeley K, Xue H, Li Y. Weaker dental enamel explains dental decay.
PLoS One. 2015 Apr 17;10(4):e0124236. doi: 10.1371/journal.pone.0124236. PMID: 25885796;
PMCID: PMC4401694.
iii
Zachrisson BU, Zachrisson s. caries incidence and orthodontic treatment with fixed appliances.
scand J Dent Res 1971;79:183-92
iv

“Selection Criteria for Dental Radiography” FGDP Guidelines, Standard 18