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How to Document a Dental Examination and Procedure Using a Dental Chart RESPIRATORY/DENTISTRY How to Document a Dental Examination and Procedure Using a Dental Chart Stephen S. Galloway, DVM Author’s address: Animal Care Hospital, 8565 Highway 64, Somerville, Tennessee 38068; e-mail: [email protected]. © 2010 AAEP. 1. Introduction and oral anatomical locations, pathologies, diag- A dental chart is a permanent record of a patient’s noses, treatments, procedures, and dental materi- dental care, and completion of a dental chart is the als. Terminology and abbreviations specific to minimum standard of care for documenting any pro- equine dentistry have also been accepted by the fessional dental procedure. Dental charting is the Academy of Veterinary Dentistry (AVD). An exten- process of recording the state of health or disease of sive glossary of veterinary dental terminology can be the teeth and oral cavity, and it is an integral part of found in veterinary dental texts.2,3 Extensive lists the examination, diagnosis, treatment planning, of the abbreviations accepted by the AVDC and the and monitoring of dental cases.1 The dental chart AVD are available online within the application provides legal documentation of the procedure per- packets for these organizations. Diagnostic and formed and facilitates communication with colleagues. treatment abbreviations commonly used by the au- The scope of this paper is limited to documenting thor are listed in Appendix A. routine equine dental care (occlusal adjustment, Although various systems for describing and num- floating, periodontal therapy, and simple extrac- bering teeth are recognized, the Modified Triadan tions). Although the purpose of this paper is not to Tooth Numbering System is the tooth-identification describe how to perform a dental examination, a system of choice in veterinary dentistry.4 This sys- thorough oral examination is prerequisite to com- tem is applicable to most domestic animal species pleting an accurate dental chart. Additionally, to and provides accurate tooth identification in both properly document any dental procedure and com- written and oral communication. Each tooth is as- municate with colleagues, practitioners must have a signed a unique three-digit number. The first digit working knowledge of dental terminology. designates the tooth’s quadrant and dentition, and the second and third digits designate the specific Standardized Terminology and Abbreviations tooth. Teeth in each quadrant are numbered se- To facilitate communication between colleagues, the quentially from the first (central) incisor (X01) dis- Nomenclature Committee of the American Veteri- tally to the third molar (X11), assuming a complete nary Dental College (AVDC) reviews, clarifies, and phenotypic equine dentition ([I 3/3 C 1/1 P 4/4 M 3/3] recommends standardized terminology for dental ϫ 2 ϭ 44). NOTES AAEP PROCEEDINGS ր Vol. 56 ր 2010 429 RESPIRATORY/DENTISTRY 101–111: Maxillary right quadrant, permanent 8. Treatment plan, implementation, drugs ad- dentition. ministered, and procedures performed 201–211: Maxillary left quadrant, permanent 9. Prognosis dentition. 10. Patient progress 301–311: Mandibular left quadrant, permanent 11. Client communication dentition. 401–411: Mandibular right quadrant, perma- 2. Materials and Methods nent dentition. The following outline describes the steps in docu- 501–508, 601–608, 701–708, and 801–808: de- menting a dental procedure using the author’s com- ciduous 100, 200, 300, 400 dentition, respec- bined format (examination and treatment) equine tively. dental chart (Appendix B): The typical domestic male horse is missing his man- I. Documentation of all veterinary cases be- dibular wolf teeth, and many domestic mares are gins with recording the owner information, additionally missing all canine teeth; therefore, the patient’s signalment, and primary com- dental formulae for male and female equids are ([I plaint for the visit. 3/3 C 1/1 P 4/3 M 3/3] ϫ 2 ϭ 42) and ([I 3/3 C 0/0 P II. The patient’s history is taken with particu- 4/4 M 3/3] ϫ 2 ϭ 38), respectively. In the Modified lar emphasis on the horse’s use, bit and bri- Triadan System, “The Rule of Four and Nine” is dle, diet, and masticatory and performance used to simplify annotation among various species problems. and variations within a species. Tooth X04 is al- III. A thorough physical examination is per- ways the canine tooth (104, 204, 304, 404), and tooth formed and documented. The clinician X09 is always the first molar (109, 209, 309, 409). must first rule out sources of systemic dis- Applying this rule, the first molarized cheek tooth ease before any elective dental procedure is (the second premolar) in domestic horses is tooth performed. Because sedative restraint is X06 (106, 206, 306, 406). required for a thorough dental examination, emphasis during the physical examination The Dental Chart should be placed on the horse’s body condi- The dental chart is a record of the condition of the tion and cardiovascular system. patient’s dentition and oral cavity. It should in- IV. After diseases of other body systems are clude a dental history, oral-examination findings, ruled out, the horse’s head is examined, and proposed and completed dental procedures, pro- abnormalities are recorded. posed future dental care, and home-care instruc- V. On completion of the external examination, tions.5 Although many small animal and human the horse is sedated for oral examina- dentists prefer a two-chart system (one chart for tion. Sedative and other medications are recording examination findings, diagnoses, and pro- recorded on the dental chart as they are posed treatment planning and a second chart for given during the procedure. recording the treatment performed), most equine VI. Oral examination includes the examination dental practitioners use a combined report for both of all tissues in the mouth. The soft-tissue the examination and treatments. The most com- findings are documented in the appropriate monly accepted chart format is an anatomical dental fill-in-the-blank section of the chart (e.g., a diagram supplemented by brief descriptions to clar- cheek laceration caused by a hard enamel ify the examination findings, diagnoses, and proce- point on the maxillary right first molar is dure performed. Most dental charts are designed abbreviated LAC/B 110). with a fill-in-the-blank and check-off format to en- VII. Dental abnormalities are documented on the sure consistent documentation. The dental chart dental diagram and explained in the exam- should include a legend for non-standardized sym- findings section of the chart using the appro- bols and abbreviations; however, the use of approved priate diagnostic abbreviation followed by AVDC/AVD abbreviations should minimize this re- the affected tooth’s Triadan number and the quirement. To meet the legal requirements of med- aspect of the tooth, when appropriate. The ical documentation, most state veterinary-practice tooth aspects are apical, coronal, occlusal, acts require that the following information be in- mesial (M), distal (D), palatal (P), lingual cluded in the medical record6: (L), and vestibular (V)7. A forward slash (/) or a space is often used between abbrevia- 1. Date tions for clarity. For example, a hook on 2. Primary complaint the maxillary right first cheek tooth is ab- 3. History breviated HK 106. 4. Physical examination findings A. Clinically missing teeth are circled on 5. Preliminary diagnosis with rule-outs the diagram and annotated by the tooth 6. Tests performed and results number and abbreviation O (e.g., an ab- 7. Diagnosis sent maxillary left second incisor is ab- 430 2010 ր Vol. 56 ր AAEP PROCEEDINGS RESPIRATORY/DENTISTRY Fig. 1. Dental diagram charting a diagonal bite 4 (DGL/4). Fig. 2. Dental diagram charting hook malocclusions on the max- illary third incisors (HK 103/203). breviated 0/202). During the mixed dentition period, unerupted molars are by describing the affected aspect of the recorded by circling the adult molar on tooth (e.g., cribbing attrition on the ves- the dental diagram. tibular aspect of the maxillary first inci- B. The presence of deciduous dentition is sors is abbreviated AT 101V/201V). annotated on the dental diagram by plac- F. Crown fractures of the incisors should be ing a single line through the adult tooth drawn on the dental chart and described number and writing in the appropriate (e.g., a crown fracture of the maxillary deciduous tooth number (e.g., 508). right third incisor is abbreviated T/FX C. Supernumerary teeth and retained de- 403CR). The extent of the fracture can ciduous teeth are drawn on the diagram be further described using the tooth-frac- and appropriately annotated (e.g., SN ture abbreviations (T/FX/) in Appendix 111, not 112, and RD 503). A. D. An unerupted or partially erupted tooth G. Iatrogenic pulp damage secondary to is usually impacted; therefore, a blind overreduction of the incisors with power maxillary right wolf tooth is abbreviated instrumentation is a common find- TI 105. ing. Exposed pulp is differentiated E. Dental malocclusions, fractures, cavities, based on its vitality and recorded (e.g., a and periodontal pockets are drawn on living, bleeding pulp in the mandibular the chart to approximate the outline of right third incisor is abbreviated T/PE/V actual finding and annotated in the ex- 203, whereas a necrotic, non-vital pulp in am-findings section. the same tooth is abbreviated T/PE/NV VIII. Malocclusions and other abnormal dental 203). findings commonly effecting the incisors in- H. Cavities (CA) should be staged according clude the following: to severity. A. Diagonal bites are defined with respect 1. Stage 1: cavities in the cementum to the mandibular incisors. DGL/3 is a only (CA1). diagonal bite in which the mandibular 2. Stage 2: cavities through the cemen- left incisors are longer than the mandib- tum and into the enamel (CA2). ular right incisors (Fig.
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