Assessment of the quality of oral squamous cell carcinoma clinical records in oral surgery with Surgical Tool for Auditing Records (STAR) scoring.

BACKGROUND: The Surgical Tool for Auditing Records scoring system [STAR] focuses on surgical record auditing with promising outcomes. It offers a structured approach to evaluating the quality of surgical notes. AIMS AND OBJECTIVES: This study aimed to assess the effectiveness of the STAR in evaluating oral surgical records and identifying areas for improvement in documentation practices. MATERIALS AND METHODS: The data was obtained from the Dental Information Archival Software (DIAS) of our institution. The sample size was determined using G*Power 3.1.9.4 software. Fifty consecutive oral surgery clinical records of oral squamous cell carcinoma patients were evaluated using STAR. Each record was reviewed for adherence to documentation standards including Initial Assessment (10 points), Follow-up Entries (8 points), Consent Documentation (7 points), Anesthesia Report (7 points), Surgical Log (9 points), and Discharge Synopsis (9 points). compiling a total STAR score (50 points). The data was tabulated in Google Sheets. The descriptive statistics with inter-observer agreement and the mean score were recorded. RESULTS: We observed that each of the 50 records received a score of 49/50 points on the STAR. Deductions were necessary in the Operative record section due to the lack of information regarding the sutures used. CONCLUSION: To summarize, this study emphasizes the effectiveness of the STAR scoring system in evaluating the quality of oral surgical records. Identifying deficiencies, particularly in documenting operative details, can improve the completeness and accuracy of patient records. It can ultimately enhance patient care and facilitate better communication among healthcare professionals.

Inaccurate Dental Charting in an Audit of 1128 General Dental Practice Records.

Fourteen dentists at different practices in the UK assessed the dental charts of 1128 patients who were new to the dentist but not new to the practice; 44% of the dental charts were found to be inaccurate. Inaccuracy of the individual practice-based charts ranged between 16% for the best performing practices to 83% for the worst: 5% of dental charts had too many teeth charted and 5% had too few teeth charted; 13% of charts had missed amalgam restorations and 18% had missed tooth-coloured restorations; 5% of charts had amalgam restorations recorded but with the surfaces incorrect (eg an MO restoration charted but a DO restoration actually present); 9% of charts had tooth-coloured restoration surfaces incorrectly recorded. For 7.5% of charts, amalgams were charted but not actually present. Other inaccuracies were also noted. The authors reinforce the requirements of the GDC, the advice of defence organizations, and the forensic importance of accurate dental charts. Clinical relevance: Dental charting forms part of the patient's dental records, and the GDC requires dentists to maintain complete and accurate dental records.

Simplifying optimal tooth-size calculations and communications between practitioners.

The purpose of this article is to present a simple method for determining the optimal sizes of anterior teeth. This is needed because of the frequency of anomalous and missing maxillary lateral incisors. In addition to anomalous and missing incisors, other factors that create challenges for the dentist and orthodontist when designing an esthetic and occlusally sound dentition are attrition, trauma, transposition, erosion, and caries. Optimal esthetics and occlusion require correctly sized teeth in proportion to themselves and the other teeth. Orthodontics, in partnership with restorative dentistry, allows doctors to accomplish the objectives of ideal occlusion and enhanced esthetics. Data compiled from previously published research enabled us to create simple formulae to determine optimal tooth sizes, an esthetic guide worksheet to use with collaborating dentists, and a sample written communication to accompany the completed esthetic guide worksheet. The method for establishing optimal tooth sizes is presented in a manner that allows easy memorization of the formulae and determination of the best dimensions for teeth without the use of a calculator.

Dental notation for primary teeth: a review and suggestion of a novel system.

BACKGROUND: Tooth designation systems are routinely used in dental practice, for identification of teeth, recording dental data and communication among dental professionals. There are various dental notations systems for the primary and permanent dentition. The most popular are the Zsigmondy-Palmer system, the Universal Numbering System, and the FDI system. Others includes the Victor Haderup system, the Woelfel system, and the MICAP system. The majority of dental notations are focused on permanent teeth and are modified for primary teeth, even though the latter erupt before the permanent dentition. CONCLUSION: Advantages and disadvantages of notations for primary dentition are discussed and compared to a new alphanumeric system for primary teeth which is considered simple and convenient.

[The importance of a fixed dental notation system within the dental clinic].

A teenager began an orthodontic treatment. During his orthodontic treatment, the orthodontist refferd the teenager to an Oral and maxillofacial surgeon to extract tooth no. 25. The orthodontist used the Palmer notation method to mark the tooth - 5 - and the Oral and maxillofacial surgeon read it as the no. 15, which is a completely different tooth according to the FDI World Dental Federation notation system. As a result, the Oral and maxillofacial surgeon extracted a healthy tooth by mistake. The teenager submitted a claim in tort for the harm he had suffered as a result of the mistake.

Frequency of errors and pathology in panoramic images of young orthodontic patients.

The aims of this study were to evaluate the frequency of errors in panoramic radiographs in young orthodontic patients, to register pathologic and abnormal conditions, and to compare these findings with the patient's record. A total of 1287 panoramic radiographs of children and adolescents (530 boys and 757 girls; mean age 14.2 years) were analyzed. The radiographs were obtained of patients referred for orthodontic treatment during a 1 year period. Four observers evaluated the radiographs for 10 common errors, pathologies, and/or anomalies. Cohen's kappa was used for the calculations of inter- and intraobserver variability. Five of the errors were divided into clinically relevant or not clinically relevant errors, i.e. errors influencing diagnosis. Only those pathological findings with a possible influence on orthodontic treatment were compared with the patient's record. Of the 1287 radiographs, 96 per cent had errors. The number of errors in each image varied between 1 and 5, and in 24 per cent of these images, the errors could be of importance for clinical decision making. The most common error was that the tongue was not in contact with the hard palate. Pathologies or anomalies were found in 558 patients and a total of 1221 findings were recorded. Findings of possible relevance for orthodontic treatment were 63, and 12 of those were registered in the patient records. Pathological findings outside the dental arches were low and could be an argument for minimizing the radiation field.

A comparison of computer- and hand-generated clinical dental notes with statutory regulations in record keeping.

INTRODUCTION: Dental patient records should be of high quality, contain information to allow for good continuity of care and clinical defence (should the need ever arise) and, ideally, facilitate clinical audit. Handwritten dental records have been assessed for their compliance to statutory regulations, but the same cannot be levelled at computer-generated notes. This study aimed to compare and analyse the compliance of both methods of data recording with statutory regulations. METHOD: Fifty consecutive sets of handwritten notes and 50 sets of computer-generated notes were audited for compliance with a number of legal requirements and desirable characteristics for dental records and the results compared. The standard set for compliance with all characteristics was 100%. RESULTS: The computer-generated notes satisfied the set standard for 8 of the 11 legal requirements and three of six desirable characteristics. The handwritten notes satisfied the set standard for 1 of 11 legal requirements and none of the desirable characteristics. A statistical difference (using a 95% confidence interval) between the two methods was observed in 5 of 11 legal characteristics and three of six desirable characteristics, all of which were in favour of computer-generated notes. CONCLUSIONS: Within the limitations of this study, computer-generated notes achieved a much higher compliance rate with the set parameters, making defence in cases of litigation, continuity of care and clinical audit easier and more efficient.

Analysis of demographic data obtained from pathology records.

INTRODUCTION: Pathologists commonly analyse patient data obtained from pathology records. Such information is useful in that it might provide an indication of changing patterns of disease, or of the aetio-pathogenesis of a disease process, but such data is seldom standardised. AIM: To determine to what extent the lack of standardisation may influence the resultant data and the conclusions drawn. MATERIALS AND METHODS: Pathology reports of all cysts diagnosed from 1994 to 2004 were retrieved. The diagnosis and site of the cyst, and the age, gender and race of patient were analysed. Comparative data from 1958 to 1992 was obtained from the text "Cysts of the oral regions". The data from the different periods was statistically compared. Only the four most common cysts were included: radicular, dentigerous, odontogenic keratocyst and nasopalatine duct cysts. RESULTS: There was no difference in frequency and site of cysts or in age of patients. Statistically significant differences were found in the gender and race comparisons. CONCLUSION: Do the differences reflect a changing pattern of disease or are they due to changes in the demographics of the patient pool from which the surgical specimens were obtained? We favour the latter. Awareness of the fact that data from either survey is not reliable due to lack of standardisation is pertinent to avoid drawing fundamental conclusions from such data.

Validity of an information and communication technology system for data capture in epidemiological studies.

The Belgian National Institute of Health Insurance is implementing an oral health data registration and surveillance system. This study aimed to develop and validate a system of electronic data capture for oral health surveys at a national level - Oral Survey-B - and to identify the advantages and disadvantages of the electronic system in comparison with the traditional handwritten data capture. Six series of full-mouth recordings simulating the clinical examination of 6 patients were set up in a Powerpoint presentation. The validation was undertaken by 52 general practitioners. A randomized one-period crossover design was used with two formats of data capture, i.e. electronic followed by handwritten or handwritten followed by electronic system. Further, 6 benchmarked handwritten forms were transferred to the electronic format. For the electronic data capture, 86.5% of the practitioners had a correct completion rate of ≥95%. The corresponding value for the handwritten data capture and transfer was 78.8% (p = 0.25, McNemar test). The overall accuracy of forms without any error was 73.4% for the electronic and 62.5% for the handwritten data capture (p < 0.001, signed-rank test). Significantly lower percentages of errors and less time were observed for the electronic data capture (p < 0.001, signed-rank test). Practitioners considered the electronic data capture as being much more difficult to carry out (p < 0.001). As information technology has turned into an ever more necessary working tool in epidemiology, there should be an important potential for uptake of further improvements in electronic data capture in the future.

MICAP--a novel system for identification and communication of dental problems.

AIM: To design a new tooth notation system to record and communicate dental and periodontal problems around the world. METHODOLOGY: The design of a new tooth notification system is based on the first letter of each tooth class, M-molar, I-incisor, C-canine and P-premolar, termed as ANAASEA letters and digits (1, 2, 3), termed as TOT digits, assigned to appropriate tooth types to record the right and left maxillary and mandibular teeth of both permanent and deciduous dentitions for specifically dental and periodontal charting and generally other dental oriented purposes. The letter 'd' is written along with the ANAASEA letters used for deciduous tooth classes. RESULTS: The MICAP system records and communicates dental and periodontal problems manually as well as electronically by using letters I, C, P, M and assigned digits 1, 2, 3. The assigned digits are written as superscript and subscript on right and left sides of letters I, C, P and M not only to identify teeth during oral examination but also in writing referral letters and submitting dental claims for various performed dental procedures. CONCLUSIONS: The identification of and communication about human teeth by the MICAP system is simple, error free and user/computer friendly.

Quality of data gathered with International Caries Detection and Assessment System (ICDAS) assessment and dentists' perceptions of completion of dental records.

BACKGROUND: The FDI World Dental Federation is engaged in a global consultation process to assess the potential challenges and impacts of the introduction of a preventive model to existing systems for caries management. OBJECTIVES: The aims of this study were to evaluate the quality of dental disease data collected with the International Caries Detection and Assessment System (ICDAS) index and dentists' perceptions with regard to the collection of data using the 'European Global Oral Health Indicators Development' (EGOHID) survey methods, and to estimate the mean time required for completion of the dental records according to the practitioners' perceptions. MATERIALS AND METHOD: The data - 2877 clinical examinations and 2877 individual assessments - were collected in 2008 using a network of 146 sentinel dentists in eight European countries. A clinical survey was completed for each participant and the dentist gave a detailed assessment of each patient investigated. RESULTS: This study shows that practitioners' perceptions have an impact on the mean time required to complete the dental record. Mistakes originate from dentists' attempts to simplify the completion of many boxes. This results in a larger number of missing data than of error codes. These missing data have an effect on the time required for information collection. CONCLUSION: The quality of the data collected will allow the establishment of recommendations based on this method.

Importance of quality in referral letters sent for potentially malignant oral, head and neck lesions.

UNLABELLED: Early diagnosis of oral, head and neck cancer is very important. Delay in diagnosis and referral to a specialist unit can result in an enlarged tumour with an increased chance of metastatic spread which will result in upstaging of the tumour, thus worsening the five year survival rate. There is a great need for early identification and referral of potentially malignant lesions by general dental and medical practitioners. Referral letters are the standard and, typically, the sole method of communicating confidential information between two professionals. It is vital that the referral letters sent for potential malignant lesions are of good quality, clearly marked as urgent and contain adequate administrative and clinical data. An audit was undertaken at the Oral and Maxillofacial Department at Barnet and Chase Farm NHS Trust, to examine the quality of referral letters sent for potentially malignant oral, head and neck lesions. The outcome is discussed and a standard referral letter is also proposed if not referring using the standard local cancer network referral proforma. CLINICAL RELEVANCE: A good quality referral letter should minimize delay in diagnoses and management of a patient with an oral, head and neck lesion.

A coding solution for supernumerary teeth.

In South Africa payments for treatment rendered are routinely delayed because of the medical fund industry's apparent inability to capture codes denoting supernumerary teeth. The suggested protocol allows for up to 13 supernumerary teeth to be identified by two digits. Meetings planned between SADA and key funding stakeholders to "ensure that protocols related to tooth numbering are acceptable", provide the ideal opportunity to introduce the suggested two-digit protocol for numbering supernumerary teeth. If this proposal is implemented, it could alleviate the frustration associated with the rejection of accounts where supernumerary teeth are appropriately identified.

Strategies for caries risk assessment in children and adolescents at public dental clinics in a Swedish county.

BACKGROUND: Since caries prevalence has decreased and become polarized, high-risk preventive strategies have been widely adopted. The underlying factors leading to assessment and management of caries risk are poorly understood. AIM: The aim of this study was to identify the factors forming the basis for dentist's caries risk assessment in dental care for children and adolescents. DESIGN: From all 3372 children in a Swedish county identified as at high risk for developing caries, a sample of dental records from 432 children, aged 3-19 years, were randomly selected to be analysed in the study. Information about medical and social history, dental status, dietary habits, oral hygiene, and salivary data was obtained from the records. RESULTS: The results show that the only data registered in the majority of the dental records were dental status from the clinical examination and bitewing radiographs. In approximately half of the dental records, medical history and data concerning oral hygiene were registered. Dental history and dietary habits were noted in approximately 25% of the dental records, whereas other risk factors/indicators were occasionally registered. CONCLUSIONS: Dentists mainly base their caries risk assessments on past caries experience, a reliable risk indicator for assessing the risk of being affected by caries again. In children with no experience of caries, knowledge of other risk factors/indicators needs to be available to perform a caries risk assessment. In this study, documentation of such knowledge was strongly limited.

Audit of dental practice record-keeping: a PCT-coordinated clinical audit by Worcestershire dentists.

UNLABELLED: A collaborative audit of clinical record-keeping standards was performed among Worcestershire dentists. AIMS: Its aims were to improve the quality of National Health Service (NHS) patient care and to assist dentists to perform well during Dental Reference Service practice visits. METHODS: Worcestershire dentists with NHS contracts were invited to take part in this audit. Each dentist audited a random selection of 30 of their dental clinical records against a common framework comprising eight domains. Record-keeping, and the presence or absence of key diagnostic and treatment planning details were recorded. Grading was applied in four categories, in which grades 1 and 2 were good (1) and adequate (2), captured on data-collection sheets and centrally analysed for frequency of each grade. RESULTS: Out of a total of 184 Worcestershire general dental practitioners, 161 (87.5%) submitted usable responses. The audit revealed wide variation between dentists in clinical record-keeping. The recording of soft tissues (36% below grade 2), periodontal status (30%), radiographic review (27%), and note-taking (25%) all fell below the standard that had been set (brackets show proportion not meeting the standard). CONCLUSIONS: The results provided baseline information about the standard of record-keeping in NHS dental practices in Worcestershire. The collaborative nature of the audit enabled dissemination of individual results to participants, to facilitate comparison (anonymously) against their peers. The audit provided impetus for the Primary Care Trust (PCT) to arrange postgraduate education on record-keeping and to raise awareness among local dentists about record-keeping. The subsequent report to dentists explored the record-keeping standards expected during practice inspections undertaken by the Dental Reference Service. Worcestershire PCT's method of collaborative dental audit could potentially replace the previous national programme of dental audit, formerly coordinated locally.