Dental Recording

Recording

The information resulting from the examination and any treatment performed needs to be recorded.

A completed dental record is a legal document that can be referred to:

• During treatment – to ensure that all treatment is performed
• At post-treatment discharge – to inform the owner of the condition of the teeth and of treatment performed
• At any time or by any person in the practice – for information related to the mouth at a specific date.

A dental chart is a diagrammatic representation of the dentition, where information (findings and treatment) can be entered in a pictorial and/or notational form. Various different charts are available. A Dentalabel® is one example of a dental chart. It provides a simple way of recording most of your findings and treatments. However, it is only a chart and needs to be supplemented by clinical notes, radiographs, etc. to form a complete dental record.

Most charts make use of the modified Triadan system (Floyd, 1991) where each tooth is allocated a three-digit number. The first number denotes the quadrant of the mouth and whether the tooth is permanent or deciduous. The second and third digits denote the tooth itself. In dogs the teeth are numbered consecutively from the midline whereas in cats, some numbers are skipped as not all teeth are present. Canine teeth are always numbered 04 and molars are always 09.

Modified Triadan System – Quadrant Numbering

Permanent Dentition

• Right upper = 1
• Left upper = 2
• Right lower = 4
• Left lower = 3

Deciduous Dentition

• Right upper = 5
• Left upper = 6
• Right lower = 8
• Left lower = 7

Dental Terminology

Terms used to describe the aspects of the tooth are different to describing other aspects of the body. These terms are used when describing where a lesion is on the tooth eg. Periodontal pocket on the palatal aspect of the upper canine. The terms can also be combined to give absolute accuracy for example distopalatal would indicate the surface of the tooth furthest away from the midline and on the aspect facing the palate.

Mid-line - refers to the centre point in the mouth between the first incisors on the left and right side, so closest to the midline is the aspect of the tooth in the arch that is closest to the midpoint of the two incisors.
Palatal – surface of the tooth towards the palate
Lingual – surface of the tooth towards the tongue
Labial – surface of the tooth towards the lips
Buccal – surface of the tooth towards the cheeks
Occlusal – surface of the tooth facing the opposite jaw
Interproximal – surface between two teeth
Mesial – surface of the tooth towards the front mid-line
Distal – surface of the tooth away from the front mid-line
Apical – towards the root
Coronal – towards the crown

Dental Chart Notation

(example of a completed dental chart on same screen as the list of abbreviations)

• NAD - No abnormality detected (not always used – usually if there is no pathology, nothing is recorded on the chart)
  
• RL - Odontoclastic resorptive lesion or TR –tooth resorption. The extent of the lesion is shaded in on the chart – the buccal view is used
  
• GR - Gingival recession - The gingival margin is drawn down on the root and the measurement is written in mm. eg.GR3. This is drawn on the buccal and/or lingual/palatal aspect
  
• GH - Gingival hyperplasia - This is measured in mm and the gingival margin is drawn out over the crown of the tooth. This is drawn on the buccal and/or lingual/palatal aspect
  
• UCF - Uncomplicated crown fracture - The extent of the fracture is shown on the buccal view of the tooth.
  
• CCF - Complicated crown fracture - #PE is also sometimes used (fracture with pulp exposure). The fracture line is drawn through the crown of the tooth
  
• W - Wear (abrasion or attrition) facet, and the wear is drawn on to the chart
  
• Ca – caries defect - Since the lesions occur on the occlusal surface of the tooth, the open mouth view/occlusal view is used to shade in the lesion
  
• G I-III - Gingivitis is graded out of 3 and recorded in the box
  
• Periodontal probing depths are recorded on the occlusal view of the tooth, and a small number representing the depth is written at the corresponding location
  
• F 1-3 – Furcation exposure
  
• M 1-3 – Mobility
  
• OM – Oral Mass - The extent of the lesion is drawn onto the chart. Either the buccal view or the occlusal view can be used depending on the location of the mass. Measurements of the mass are also recorded
  
• RR – Root Remnants that are visible or felt during the examination, rr is recorded at the site.
  
• Missing teeth are usually circled. In cases of dispute, it is essential to have a recorded of missing teeth prior to the procedure so this should always be recorded.
  
• Extracted teeth are usually marked with a X

Ensure that all abnormal findings are recorded on the chart and, where possible, give details including location, severity, size (mm) & direction.