Audit on the Use of Radiographs Prior to Stainless Steel Crown Placement

Stainless steel crowns (SSC) are a valuable restorative option in paediatric patients due to their high clinical effectiveness [1-3]. Literature has suggested reduced failure rates in SSC placed with hall and conventional techniques for primary molars versus restorations such as glass ionomer cement (GIC), composite and amalgam [1]. In order to appropriately plan treatment, teeth need to be assessed for suitability for SSC placement, which includes pre-operative radiographs [2]. Radiographs can be used in the assessment of contraindications to SSC placement [1-3] such as there being no sound band of dentine between carious lesions and the pulp [2] and evidence of radiographic pulpal involvement or infection [3]. To assess and improve compliance of clinicians within a community dental service in taking preoperative radiographs prior to placing stainless steel crowns. UK national clinical guidelines for SSCs advise taking pre-operative radiographs prior to placement on primary molars [1]. This standard has been adapted to account for the patient groups (e.g., pre-cooperative patients) treated in the community dental service where radiographs may not be possible. In assessing Question 3, the relevant medical history was reviewed for factors that could have affected the ability to take radiographs, including learning disabilities, autism spectrum disorder and behavioural or mental health conditions. When assessing Question 4, possible written justification for not attempting radiographs included if the patient was a pre-cooperative child or if the teeth being crowned were hypomineralised non-carious teeth. Individual clinician data for the first cycle was collected in order to allow for individual feedback to be provided to staff members if required, and this was emailed across if the staff member asked for their data but was anonymised for analysis and presentation of results. Data collection for both cycles was conducted using an electronic Audit Management and Tracking (AMAT) proforma. Between the first and second cycle of the audit, an action plan was implemented. A retrospective second cycle audit was conducted between 25 February 2023 and 25 February 2024 using the same methods as the first cycle. In the first cycle of the audit, 11 clinicians and 161 crowns were audited, while in the second cycle, 11 clinicians and 174 crowns were audited. The results of both cycles are summarised in Table 1. Within the first cycle, there was no relevant medical history noted. Within the second cycle, there were three patients whose medical history was deemed to have contributed to issues with cooperation with radiographs prior to crown placement. Two of these patients had two crowns placed each, leading to a total of five crowns. This involved two crowns placed on a patient with autism, pathological demand avoidance and developmental delays, two crowns placed on a patient with autism and one crown placed on a patient with attention-deficit hyperactivity disorder (ADHD) and suspected autism. Teaching was delivered on the importance of taking radiographs prior to placing stainless steel crowns, along with a presentation of the first cycle of audit data and its analysis at a peer review meeting within the community dental service. A clinical record keeping template for stainless steel crown treatment was created and emailed to clinicians. Finally, a label for the stainless steel crown box designed to remind the clinician to take a radiograph prior to placement of a SSC or to record the justification for not taking a radiograph was created and disseminated to all clinics within the service (Figure 1). In the second cycle there was a slightly increased frequency of crowns placed; this could be due to the education provided within teaching on indications for and benefits of stainless steel crowns. There was a marked improvement in results between the first and second cycles. This included both more pre-operative radiographs being taken and an improvement in record keeping when radiographs were not taken. In the second cycle, there were more attempts to take radiographs; therefore, there was an overall increase in both the proportion of crowns placed with pre-operative radiographs present (Question 1) as well as evidence of unsuccessful attempts to take radiographs (Question 2). There was a focus on good documentation in the actions implemented after the first cycle; therefore, in the second cycle, the standard was met in 94% of cases where crowns were placed (Question 5). A limitation of the audit is that there was sometimes subjectivity as to whether certain words meant that a radiograph had been attempted but unsuccessful or not attempted at all as the patient was deemed pre-cooperative, for example the interpretation of the word ‘uncooperative’, therefore these were included as ‘other written justifications’ (Question 4). Another limitation is that the second cycle sample period commenced 3 months after the action plan had been implemented when clinicians were more acutely aware of the standards. As there was high compliance against the standard with 94% compliance against a target of 100%, no further changes were recommended for implementation. A follow-up audit at 12 months was recommended to determine if a high compliance was maintained. Overall, this project was successful. This is the first time this topic has been audited within this NHS Foundation Trust, and after the second cycle, there was a large increase in the number of pre-operative radiographs taken prior to stainless steel crown placement. Clinicians are now more knowledgeable on the reasons for taking pre-operative radiographs during treatment planning for stainless steel crowns and are able to make informed decisions with their patients on which primary molars would benefit from this treatment. The authors declare no conflicts of interest.