Accepted: 2 October 2017

DOI: 10.1111/eje.12297

ORIGINAL ARTICLE

Clinical audit training improves undergraduates’ performance

in root canal therapy

J. Y. M. Fong | V. J. H. Tan | J. R. Lee | Z. G. M. Tong | Y. K. Foong | J. M. E. Tan |

A. Parolia | A. Pau

Division of Clinical Dentistry, School of

Dentistry, International Medical University, Abstract
Kuala Lumpur, Malaysia Aim: To evaluate the effectiveness of clinical audit-­feedback cycle as an educational
Correspondence tool in improving the technical quality of root canal therapy (RCT) and compliance with
Abhishek Parolia, Division of Clinical record keeping performed by dental undergraduates.
Dentistry, School of Dentistry, International
Medical University, Kuala Lumpur, Malaysia. Methods: Clinical audit learning was introduced in Year 3 of a 5-­year curriculum for
Email: [email protected] dental undergraduates. During classroom activities, students were briefed on clinical
audit, selected their audit topics in groups of 5 or 6 students, and prepared and pre-
sented their audit protocols. One chosen topic was RCT, in which 3 different cohorts
of Year 3 students conducted retrospective audits of patients’ records in 2012, 2014
and 2015 for their compliance with recommended record keeping criteria and their
performance in RCT. Students were trained by and calibrated against an endodontist
(κ ≥ 0.8). After each audit, the findings were reported in class, and recommendations
were made for improvement in performance of RCT and record keeping. Students’
compliance with published guidelines was presented and their RCT performances in
each year were compared using the chi-­square test.
Results: Overall compliance with of record keeping guidelines was 44.1% in 2012,
79.6% in 2014 and 94.6% in 2015 (P = .001). In the 2012 audit, acceptable extension,
condensation and the absence of mishap were observed in 72.4, 75.7% and 91.5%; in
the 2014 audit, 95.1%, 64.8% and 51.4%; and in 2015 audit, 96.4%, 82.1% and 92.8%
of cases, respectively. In 2015, 76.8% of root canal fillings met all 3 technical quality
criteria when compared to 48.6% in 2014 and 44.7% in 2012 (P = .001).
Conclusion: Clinical audit-­feedback cycle is an effective educational tool for improving
dental undergraduates’ compliance with record keeping and performance in the
technical quality of RCT.

KEYWORDS
clinical audit, dental education, dental undergraduates, endodontics, feedback

1 | INTRODUCTION a tool to review conformity to defined standards of healthcare provi-

sion.2,3 Today, clinical audit has come to be regarded as a cornerstone
Clinical audit has been defined as a quality improvement process that of effective clinical governance, having been made a requirement in
seeks to improve patient care and outcomes through systematic review clinical practice by the National Health Service and other professional
of care against explicit criteria and the implementation of change.1 regulatory bodies.4 The clinical audit cycle repeated at appropriate in-
Clinical audits have been introduced to dentistry since the 1960s as tervals to assess for the implementation of change, providing essential

Eur J Dent Educ. 2017;1–7. wileyonlinelibrary.com/journal/eje © 2017 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 | FONG et al.

feedback to ensure further improvement and consistent quality to op- of the International Medical University, Kuala Lumpur, Malaysia. Teeth
5
timise patient outcomes has found to be important. The regulatory having pre-­operative and post-­operative radiographs were included,
bodies and specialist interest groups involved in dental education such and the records of treatment that have yet to be completed or were
as General Dental Council and Association for Dental Education in lacking post-­operative radiographs were excluded from the study. All
Europe have emphasised the need for dental students to be exposed root canal treatment performed by undergraduate dental students fol-
6,7
to, and trained in how to, complete clinical audits. However, the evi- lowed a standard hybrid method using K-­files for all cases as reported
dence for an appropriate training to carry out clinical audit and the ef- previously by Wong et al25
ficacy of the audit-­feedback mechanism within dental school teaching Five dental undergraduate students were trained during a 1-­hour
curriculum have remained indefinite..8,9 The technical standard of root seminar for the radiographic assessment of technical quality of end-
canal treatment has been shown to be closely linked to success,10 and odontic fillings. Following the seminar, the student examiners were
the post-­operative radiograph of the completed root canal treatment calibrated by independently assessing 20 sample cases of radiographic
acts as a “proxy” assessment of technical quality.11 Many studies have records of root canal treated teeth. The results of the examination by
reported the quality and outcomes of endodontic treatment world- the undergraduate students were compared with the values obtained
12-22
wide with varying results. However, at present, there are limited from an endodontist; the calibration was repeated until a minimum
publications in the literature that explores the possibility of a clinical inter-­ and intra-­examiner κ value of 0.70 was achieved. The κ value for
audit-­feedback cycle in improving the quality of endodontic treatment intra-­ and interexaminer agreement was 0.74, 0.80 and 0.89 during
and record keeping.23 Therefore, this study was aimed to embed the the first, second and third audit cycles, respectively.
clinical audit training and evaluate the effectiveness of clinical audit-­ Radiographic images obtained were enhanced and viewed by 5
feedback cycle as an educational and quality improvement tool in a student evaluators under magnification on a computer screen using
dental undergraduate programme. VixWin Platinum software (Gendex Dental Systems, Hatfield, PA,
USA) in a dark room. The images were divided equally into 2 groups
to be examined. For example, the 150 cases in 2012 were divided into
2 | MATERIALS AND METHODS groups of 75 teeth each and viewed by 2 or 3 students independently.
Whenever there was a discrepancy between the evaluators, the case
Year 4 dental undergraduates at the International Medical University was re-­examined by the endodontist for a definitive evaluation. The
received clinical audit training as part of their curriculum. The training overall quality of endodontic obturation was assessed based on the
involved a 1-­hour classroom plenary on the principles and method- density, length of filling from the radiographic apex and occurrence of
ologies of clinical audit followed by a 3-­hour seminar in which 6 or 7 procedural errors. In multirooted teeth, the quality of obturation was
groups of 5 to 6 students, depending on the year of study, presented deemed acceptable only when the endodontic filling of all canals was
their audit protocols for the topics they had selected. The objectives found to be acceptable. The clinical records kept by the students were
were that students, after the training, should be able to (i) demonstrate retrieved from the Open Dental software and printed out. The printed
an understanding of clinical audit, (ii) describe the audit cycle and (iii) records were independently audited against the predetermined check-
apply the audit cycle to their clinical performance in a chosen topic. list as adapted from the guidelines issued by the European Society of
Following the plenary, students were asked to propose and research Endodontology.24 The presence or absence of recording of each cri-
a topic for the practical clinical audit exercise. In their presentation of terion (total = 17) was observed: use of an pulp sensibility test, use of
their proposal, they were asked to cover the following areas of the local anaesthesia, name of local anaesthesia, dosage of local anaes-
audit cycle: (i) objectives of the audit; (ii) the guidelines or criteria to thesia, use of rubber dam isolation, working length, reference point
be used, with referencing; (iii) mechanism for data collection, including of working length, size of initial apical file, size of master apical file,
training and calibration; and (iv) data analysis strategy, including data applied intracanal dressing, medication prescribed including analgesics
manipulation and presentation. On completion of their audits, each and antibiotics, size of master cone, pre-­operative radiograph, working
group of students presented their findings to the whole class in a 3-­ length radiograph, master cone radiograph, post-­operative radiograph
hour seminar and made recommendations for improvements. and advice on final restoration in the follow-­up visit. The data were
This study reports on a series of clinical audits carried out by re- entered into a Microsoft Excel 2013 (Microsoft, Redmond, WA, USA)
spective cohorts of undergraduates from 2012 to 2015 on their per- template checklist by each evaluator. The combined data from each
formance in root canal therapy (RCT). After a systematic online review audit were tabulated, analysed and compared with SPSS version 18.0
of the literature, the students identified specific evaluation criteria in (SPSS, Inc., Chicago, IL, USA). Pearson chi-­square tests were carried
compliance with standards adapted from the guidelines defined in the out to determine the potential association between the quality of RCT
consensus report of the European Society of Endodontology.24 These and associated factors. The significance level was set at P < .05.
criteria were used to formulate a detailed audit checklist and protocol. The first audit was performed in 2012 on clinical cases that were
Retrospective clinical audits were carried out by the audit team completed from January 2011 to April 2012. After first audit cycle in
on electronic and digital radiographic records retrieved from the elec- 2012, the results were presented as a 3-­hour seminar in a classroom
tronic software records (Open Dental) of all teeth that were endodon- setting to students in the same cohort and all dental faculty members.
tically treated by Year 3, 4 and 5 students in the Oral Health Center The deficiencies were highlighted in lectures to subsequent cohorts
FONG et al. | 3

and clinical supervisors. After obtaining the feedback, all endodon- 152 teeth in 2012, 142 teeth in 2014 and 56 teeth in 2015. Thirty-­
tists had a discussion regarding the preparation of endodontic guide- two teeth in the year 2015 were still undergoing endodontic treat-
lines to be followed in the clinical setting. Approval from the school ment; therefore, they were not included.
was obtained, and recommendations were made for improvements. Of the records examined, 44.1% were assessed to be compliant
Endodontic guidelines were implemented in the curriculum, and all with the record keeping guidelines in 2012. This was followed by a
students performing RCT were made aware of key areas for improve- significant increase in compliance to 79.6% and 94.6%, in 2014 and
ment. These guidelines were reinforced by delivering in the form of 2015, respectively (P < .001). Significant differences were noted for
plenaries and uploading on the online learning portal and chair-­side pulpal sensibility testing (P < .001), type and dosage of local anaes-
desktop computers for their reference. Clinical supervisors were called thetic agent (LA) administered (P < .001), usage of rubber dam for iso-
for a discussion and they were standardised by a programme delivery lation (P < .001), size of initial apical file (IAF) used (P < .001), sizes of
and advised to perform a closer clinical supervision and thorough re- master gutta percha (GP) cones used (P < .001), master GP radiograph
view of the records before signing off. recorded (P = .01), and working length radiograph recorded (P < .001).
The clinical audit was repeated similarly in 2014 and 2015 to A detailed comparison of the criteria for record keeping evaluated be-
assess for changes that may have taken place after each successive tween each audit cycle is displayed in Table 1.
cycle. Hence, a total of 350 endodontic cases were evaluated through- No mishaps were reported in 91.5% of cases in 2012, 51.4% of
out the 5-­year span from 201l to 2015. cases in 2014 and 92.8% of cases in 2015, respectively (P < .001).
Significant differences were noted for ledging (P < .001) and gouging
errors (P < .001). Occurrences of mishaps are compared in Table 2. The
3 | RESULTS types of mishaps are illustrated in Figure 1.
The overall quality of root filling deemed acceptable was 44.7% in
A total of 350 teeth that had satisfied the inclusion criteria were as- 2012. This was followed by a slight increase to 48.6% in 2014 and a
sessed throughout the 3 clinical audit cycles that were conducted: significant increase to 76.8% in 2015 (P = .001). Significant differences

T A B L E 1 Compliance with record

Criteria Recorded In Clinical χ2 test
keeping guidelines
Notes 2012 (n = 152) 2014 (n = 142) 2015 (n = 56) P-­value

Pulpal sensibility tests 53.9% 75.4% 83.9% <.001

performed
LA administered 25.0% 50.7% 67.9% <.001
Type of LA recorded 17.1% 47.2% 64.3% <.001
Dosage of LA recorded 13.8% 35.2% 55.4% <.001
Use of rubber dam for 15.8% 91.5% 85.7% <.001
isolation
Working length recorded 97.4% 100.0% 100.0% .072
Reference point for working 67.1% 61.3% 51.8% .123
length recorded
Size of IAF recorded 67.8% 97.9% 94.6% <.001
Size of MAF recorded 94.7% 98.6% 92.9% .103
Placement of intracanal 75.7% 81.0% 89.3% .086
medicament recorded
Prescribed systemic 8.6% 10.6% 1.8% .129
medication recorded (if any)
Size(s) of master GP cone(s) 61.2% 54.9% 87.5% <.001
used recorded
Pre-­operative radiograph 93.2% 97.2% 100.0% .183
recorded
Working length radiograph 90.8% 99.3% 100.0% <.001
recorded
Master GP radiograph 94.1% 99.3% 100.0% .010
recorded
Post-­operative radiograph 93.4% 90.8% 100.0% .064
recorded
Overall acceptance of record 44.1% 79.6% 94.6% <.001
keeping
4 | FONG et al.

TABLE 2 Occurrence of mishaps

χ2 test
Types of Mishaps 2012 (n = 152) 2014 (n = 142) 2015 (n = 56) P-­value

Ledging 3.3% 26.1% 1.8% <.001

Perforation 2.6% 4.9% 0.0% .212
Gouging 0.0% 16.2% 3.6% <.001
Separation of 1.3% 1.4% 0.0% .660
instrument inside canal
Others (zipping, 1.3% 0.0% 1.8% .886
transportation etc.)
Absence of Mishaps 91.5% 51.4% 92.8% <.001

(A) (B) (C)

(D) (E) (F)

(G) (H)

F I G U R E 1 Periapical radiographs
showing (A): obturation within normal
limit, (B): under-­extended obturation, (C):
over-­extended obturation, (D): zipping of
the canal, (E): gouging of the canal, (F):
perforation of the canal, (G): homogenous
obturation, (H): non-­homogenous
obturation

were noted for occurrences of underobturation (P < .001), overobtura- interventions that were introduced following each audit by address-
tion (P < .001), well-­obturated canals (P < .001) and homogenous root ing key weaknesses that were identified. The audits were performed
canal fillings (P = .025). The radiographic evaluation of endodontic fill- entirely by trained dental students with the aim to incorporate and
ings is compared in Table 3. inculcate the practice of clinical audit which is an integral aspect of
clinical governance in daily clinical practice. The high κ value of 0.89
indicates an excellent and reliable interexaminer agreement when as-
4 | DISCUSSION sessing the specified criteria.
The technical quality of root canal fillings had been investigated
Clinical audit was introduced into the clinical endodontic training in previous studies based on the evaluation of radiographic images
for undergraduate students at the school of dentistry, International of endodontically treated teeth.16 In the present study, the quality of
Medical University in 2013. Subsequently, 2 other audits were con- endodontic treatment was evaluated based on the extent and density
ducted in 2014 and 2015, respectively, thus completing 2 audit-­ of root canal fillings, as well as the absence of mishaps when assessed
feedback cycles (Figure 2). The clinical audit process was repeated on digital radiographic images which are able to provide detailed, con-
to assess the effectiveness of the feedback and multifaceted sistent and reproducible image quality standards.
FONG et al. | 5

T A B L E 3 Radiographic quality of root

Quality of root canal χ2 test
canal obturation
obturation 2012 (n = 152) 2014 (n = 142) 2015 (n = 56) P-­value

Under-­extended 15.8% 4.2% 3.6% <.001

Well-­extended 72.4 95.1% 96.4% <.001
Over-­extended 11.8% 0.7% 0.0% <.001
Homogenous root 75.7% 64.8% 82.1% .025
canal filling
Overall acceptable 44.7% 48.6% 76.8% .001
root canal fillings

FIGURE 2 The endodontic audit-­feedback cycle

In spite of the general guidelines of record keeping established dental students towards recording certain items that may have been
in the IMU Oral Health Center, overall compliance to record keeping thought of as being less important and therefore were omitted from
criteria during endodontic treatment was found to be unsatisfactory the records. Alternatively, in some cases, these gaps in recorded in-
in 2012. This was reflected in the frequent absence in recording of formation may be an indication of steps that may have been missed
essential aspects in 2012 such as the local anaesthetics (LA) admin- or that were deemed unnecessary in a particular clinical case, such as
istered and the usage of rubber dam, whereby only 13.8% of records the administration of local anaesthesia in a tooth with pulpal necro-
had mentioned the dosage of LA administered and 15.8% of cases sis. Drawing upon the overall unsatisfactory level of record keeping
recorded the use of rubber dam during endodontic treatment. Only achieved in 2012, guidelines with greater clarity in endodontic record
53.9% of records had mentioned the use of pulpal sensibility testing as keeping that was based on the consensus report of the European
an investigative tool in determining the pulpal status of the tooth prior Society of Endodontology were prepared and disseminated to all den-
to root canal treatment. This may be due in part to the indifference of tal students and supervisors within the undergraduate endodontic
6 | FONG et al.

programme.24 The results of the initial audit were presented to stu- of clinical endodontic training to encourage constant self-­assessment
dents and faculty members by members of the audit team using a and reflection against specified standards. Clinical performance with-
power point presentation in a classroom setting, and specific areas out feedback or evaluation has the tendency to reinforce errors rather
of weaknesses were identified. The importance of each criteria was than to correct them.26 Besides disseminating the results and feedback
emphasised during pre-­clinical lectures as well as during the clinical of the audit to the student clinicians involved and their supervisors, the
sessions in the clinic. Clinical supervisors were encouraged to review findings of the audit were also used as feedback for other further inter-
the records prior to approving cases that were submitted for assess- ventions such as the improvisation of teaching methods and protocols
ment. These approaches led to an exponential improvement in overall of clinical supervision in the undergraduate endodontic programme.
record-­keeping practices, achieving 79.6% and 94.6% compliance in This multidirectional approach was able to address key areas of weak-
2014 and 2015, respectively (P < .001). nesses and enhance clinical performance towards a higher standard of
75.7% of dental undergraduates achieved satisfactory condensa- quality in endodontic treatment in a dental school setting.
tion in 2012. However, there was a slight decline in quality of con- Within the limitations of this study, the clinical audit-­feedback cycle
densation to 64.8% in 2014 and a subsequent rise to 82.1% in 2015 when applied in an undergraduate endodontic training programme was
(P = .025). No mishaps were reported in 91.5% of cases in 2012, 51.4% found to have the potential to enable undergraduate dental students
of cases in 2014 and 92.9% of cases in 2015, respectively (P < .0001). and their clinical mentors to identify specific areas for improvement,
The slight decrease in degree of condensation and the acute increase which may differ for each student clinician. A review of the findings
in mishaps in 2014 may be attributable to insufficient adherence to of the audit also allows students to identify methods to prevent and
clinical principles of endodontics such as the adequate preparation of minimise risks for procedural mishaps. The student-­driven clinical audit
teeth to achieve a straight-­line access and optimum taper. Another process may equip dental students to have a sense of ownership in
possible contributing factor identified was the improper assignment conducting self-­assessment and to identify cases or characteristics
of complex endodontic cases to dental students who were not suffi- that indicate complexity according to their current competencies that
ciently equipped to manage them. In line with the findings of the end- may indicate the need to refer to another practitioner (including a more
odontic audit in 2014, feedback was provided to the dental students senior student clinician) or specialist with greater experience and com-
and clinical supervisors in the form of a presentation of the findings petency level to ensure optimal standards of care for each patient.
of the audit. The basic principles of root canal cleaning, shaping and From the perspective of dental educators, the audit process has
obturation were further emphasised in the pre-­clinical curriculum. the potential to enable the identification of problem areas within the
Clinical cases were assigned more strictly and based on the clinical curriculum, methodology, instruments or materials used, and subse-
competencies achieved by each student as approved by the supervi- quently to work towards overcoming them with guidelines or greater
sor. The level of clinical supervision was also heightened in order to emphasis within the current curriculum. The effectiveness of these in-
ensure compliance to the clinical standards at each stage of treatment terventions may be further assessed after changes have been made in
thereby increasing the quality of condensation and minimising the oc- subsequent audit cycles.
currences of mishaps encountered in the clinical cases as observed by During the process of the audit, it was observed that there were
an improved performance in the subsequent audit performed in 2015. varying degrees of competencies achieved by undergraduate dental
In terms of acceptable extension, only 72.4% of teeth treated by students. Various contributing factors were identified for this phe-
dental undergraduates were evaluated to be within 1 mm from the nomenon such as the degree of clinical supervision or compliance to
radiographic apex in 2012. There was a significant improvement in the guidelines. This enabled the faculty to prepare objective and practica-
length of extension to 95.1% in 2014 and a further slight improvement ble measures within guidelines that enable standardisation and con-
to 96.4% in 2015 (P < .001). sensus to improve consistency in the quality of treatments achieved.
The steady overall improvements in quality of endodontic fillings The clinical audit exercise also encourages an evidence-­based ap-
deemed acceptable is a testament of the effects of a multifaceted ap- proach in endodontic treatment through statistically measurable out-
proach to quality improvement, spearheaded by the endodontic audit-­ comes with research-­validated gold standards and critical comparisons
feedback cycle. The final results achieved in 2015 indicate a high level of performance with current available outcomes published in the liter-
of overall quality of endodontic fillings that compare favourably to the ature both locally and internationally.
quality standards achieved by undergraduate dental students in other
institutions worldwide.12,13,17,18,20,22
The exponential improvement in the record-­
keeping practices 5 | CONCLUSION
achieved following the audit-­feedback cycles supports the findings
of the systematic review performed by Jamtvedt and colleagues, who Based on the results of this study, the clinical audit-­feedback cycle was
concluded that the audit-­feedback cycle is more likely to affect greater found to be an effective educational tool for improving dental under-
change when baseline compliance with clinical guidelines is poor or graduates’ compliance with record keeping and to enhance the quality
when the feedback provided is intensified.9 According to the under- of RCT. However, the improvement in technical quality of root canal
graduate curriculum guideline for endodontology developed by the filling was not only because of a better compliance of record keeping
European Society of Endodontology, feedback is an integral aspect but also due to the continuous improvement in teaching/supervision/
FONG et al. | 7

practice/execution of treatment over the years. Therefore, the posi- 10. Sjögren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the
tive results presented in this study were attributable to the multifac- long-­term results of endodontic treatment. J Endod. 1990;16:498‐504.
11. Whitworth J. Methods of filling root canals: principles and practices.
eted approaches taken that were driven by the findings of this clinical
Endod Topics. 2005;12:2‐34.
audit-­feedback cycle. 12. De Quadros I, Gomes BP, Zaia AA, Ferraz CC, Souza-Filho FJ.
Further studies on the endodontic audit-­feedback cycle conducted Evaluation of endodontic treatments performed by students in a
across multiple centres are required to evaluate the effects when ap- Brazilian Dental School. J Dent Educ. 2005;69:1161‐1170.
13. Balto H, Al Khalifah S, Al Mugairin S, Al Deeb M, Al-Madi E. Technical
plied in other settings such as postgraduate training or amongst other
quality of root fillings performed by undergraduate students in Saudi
clinicians. Future studies may also explore the effects of clinical audit Arabia. Int Endod J. 2010;43:292‐300.
on the long-­term success of endodontically treated teeth. 14. Segura-Egea JJ, Jimenez-Pinzon A, Poyato-Ferrera M, Velasco-Ortega
E, Rios-Santos JV. Periapical status and quality of root fillings and
coronal restorations in an adult Spanish population. Int Endod J.
ACKNOWLE DG E MEN TS 2004;37:525‐530.
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The authors would like to acknowledge the help of Ms. Chan Choi of endodontic treatment in an adult Irish population. Int Endod J.
Wan and Ms. Nor Kholidah for their kind assistance in the preparation 2005;38:81‐86.
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