Maintaining proper dental records.

Referred to as Standard of Care, the legal duty of a dentist requires exercising the degree of skill and care that would be exhibited by other prudent dentists faced with the same patient-care situation. Primarily, the goal of keeping good dental records is to maintain continuity of care. Diligent and complete documentation and charting procedures are essential to fulfilling the Standard of Care. Secondly, because dental records are considered legal documents they help protect the interest of the dentist and/or the patient by establishing the details of the services rendered. Patients today are better educated and more assertive than ever before and dentists must be equipped to protect themselves against malpractice claims. Every record component must be handled as if it could be summoned to a court room and scrutinized by an attorney, judge or jury. Complete, accurate, objective and honest entries in a patient record are the only way to defend against any clinical and/or legal problems that might arise. Most medical and dental malpractice claims arise from an unfavorable interaction with the dentist and not from a poor treatment outcome. By implementing the suggestions mentioned in this course, dental health care professionals can minimize the legal risks associated with the delivery of dental care to promote greater understanding for patients of their rights and privileges to their complete record.

Electronic dental record use and clinical information management patterns among practitioner-investigators in The Dental Practice-Based Research Network.

BACKGROUND: The growing availability of electronic data offers practitioners increased opportunities for reusing clinical data for research and quality improvement. However, relatively little is known about what clinical data practitioners keep on their computers regarding patients. METHODS: The authors conducted a web-based survey of 991 U.S. and Scandinavian practitioner-investigators (P-Is) in The Dental Practice-Based Research Network to determine the extent of their use of computers to manage clinical information; the type of patient information they kept on paper, a computer or both; and their willingness to reuse electronic dental record (EDR) data for research. RESULTS: A total of 729 (73.6 percent) of 991 P-Is responded.A total of 73.8 percent of U.S. solo practitioners and 78.7 percent of group practitioners used a computer to manage some patient information, and 14.3 percent and 15.9 percent, respectively, managed all patient information on a computer. U.S. practitioners stored appointments, treatment plans, completed treatment and images electronically most frequently, and the periodontal charting, diagnosis, medical history, progress notes and the chief complaint least frequently.More than 90 percent of Scandinavian practitioners stored all information electronically.A total of 50.8 percent of all P-Is were willing to reuse EDR data for research, and 63.1 percent preferred electronic forms for data collection. CONCLUSION: The results of this study show that the trend toward increased adoption of EDRs in the United States is continuing, potentially making more data in electronic form available for research. Participants appear to be willing to reuse EDR data for research and to collect data electronically. CLINICAL IMPLICATIONS: The rising rates of EDR adoption may offer increased opportunities for reusing electronic data for quality improvement and research.

Smile design and treatment planning with the help of a comprehensive esthetic evaluation form.

Even if a clinician possesses basic knowledge in esthetic dentistry and clinical skills, many cases presenting in modern dental practices simply cannot be restored to both the clinician's and the patient's expectations without incorporating the perspectives and assistance of several dental disciplines. Besides listening carefully to chief complaints, clinicians must also be able to evaluate the patient's physical, biologic, and esthetic needs. This article demonstrates the use of a smile evaluation form designed at New York University that assists in developing esthetic treatment plans that might incorporate any and all dental specialties in a simple and organized fashion.

Alterações sistêmicas e consumo de fármacos entre usuários das clínicas de Odontologia, Belo Horizonte, 2004

Considerando a importância da avaliação de sistemas para o atendimento odontológico, avaliou-se a prevalência de alteações sistêmicas e da utilização de medicamentos entre usuários das clínicas odontológicas de um curso de Odontologia em Belo Horizonte, Minas Gerais e os fatores associados à utilização de fármacos, 2004...

[Patterns of tooth agenesis. A numerical code for describing dental agenesis]. / Patronen van ontbrekende gebitselementen. Een numerieke code om dentale agenesieën te beschrüjven.

A genetic or developmental disorder can be the basis for the failure of a normal dental development, resulting in the absence of 1 or more teeth. For genetic research or the development of a plan of treatment, it is important to determine whether certain patterns of dental agenesis are more common than others. In the present article a new method is described where unique values are assigned to certain patterns of tooth agenesis. Using the idea of binary arithmetic, the absence or presence of teeth are represented by 1 and 0, and translated into corresponding unique values, the 'tooth agenesis code' (TAC). This procedure has advantages over existing methods in that it allows for easier data analysis, can contribute to genetic research into the aetiology of tooth agenesis and enables researchers to communicate unequivocally the phenotypes of their studied case. It can also be used in other areas of oral pathology that require pattern recognition.

Classifications used by Australian forensic odontologists in identification reports.

Forensic odontologists are repeatedly called upon to assist in the identification of deceased persons. A great deal of information is available in the literature as to how and why comparative dental investigation of identification is performed but there is little information on the descriptive terms used in reporting these identifications. A forensic odontology report sets out the findings of a comparison between antemortem and postmortem evidence and indicates the odontologist's opinion on the identification. This opinion needs to be defendable in a court of law. This paper investigates the classifications utilised in the six states and two territories of Australia and reflects on the differences. Three states of Australia use American Board of Forensic Odontology classifications, whilst the remaining regions use a modified format. Since there are no significant legal, cultural or religious differences, and similar practitioners and clients, variation between regions within Australia would seem hard to justify. National standard terminology should be encouraged.

A numeric code for identifying patterns of human tooth agenesis: a new approach.

Human tooth agenesis involves the absence of one or more teeth and often refers to a genetic or a developmental disorder. Identifying whether certain patterns of tooth agenesis are more prevalent than others may prove valuable for treatment planning, as well as for genetic research into its etiology and development. In the present article a method is described where unique values are assigned to patterns of tooth agenesis. Using the idea of binary arithmetic, the absence or presence of teeth are represented by 1 and 0, and translated into corresponding unique values, the Tooth Agenesis Code (TAC). This procedure has an advantage over existing methods in that it allows for easier data analysis. The method described in this article can advance genetic research towards the etiology of tooth agenesis, allows researchers to communicate unequivocally the phenotypes of their studied cases and it can be used in other areas of oral pathology that also require pattern recognition.

The ABO discrepancy index: a measure of case complexity.

A criterion for determining the acceptability of a case presented for the American Board of Orthodontics (ABO) Phase III clinical examination is case difficulty. Case difficulty can often be subjective; however, it is related to case complexity, which can be quantifiable. Over the past 5 years, the ABO has developed and field-tested a discrepancy index, made up of various clinical entities that are measurable and have generally accepted norms. These entities summarize the clinical features of a patient's condition with a quantifiable, objective list of target disorders that represent the common elements of an orthodontic diagnosis: overjet, overbite, anterior open bite, lateral open bite, crowding, occlusion, lingual posterior crossbite, buccal posterior crossbite, ANB angle, IMPA, and SN-GoGn angle. The greater the number of these conditions in a patient, the greater the complexity and the greater the challenge to the orthodontist. The ABO is considering several options for applying the discrepancy index to the Phase III clinical examination.

Retrospective investigation of dental records used in forensic identification cases.

The purpose of this paper was to investigate the standard of dental record keeping from a sample of forensic records retrieved from the Department of Oral Pathology and Oral Biology, School of Dentistry, University of Pretoria. Forty of the most recent cases in which ante-mortem information was required, were analysed. From the investigation it was clear that dentists did not comply with the requirements pertaining to dental charting and record keeping. A recommended code of abbreviations is proposed for use by dentists. It is concluded that until such time as charting is reinstituted as a legal requirement by the Health Professional Council of South Africa, dentists would not routinely chart their patients' dental status.

[Management of dental records: an example of the Department of Restorative Dentistry of the School of Odonto-Stomatology in Abidjan]. / Gestion de la fiche dentaire: exemple du service d'odontologie conservatrice de la Faculté d'Odonto-Stomalogie d'Abidjan.

The patient's file is often mismanaged because of the crowd and the frequency of emergencies caused by pain. The practitioner is worrying about handling it in first place. The objective of this work is to recall the importance of a good management of the dental records and to suggest a charting system. The interest of the dental chart, fundamental part of the patient dental file, is described before developing the implications related to an adequate management. The charting system of the service of Operative Dentistry and Endodontics of Abidjan Dental school is described. It translates the target of a good dental records management, which presents appreciable assets for practitioner, patient and administration.