Difference between revisions of "Dental Recording"

Latest revision as of 13:53, 2 November 2014

Examples of dental charts© Lisa Milella 2013

The information resulting from an oral examination and any treatment performed needs to be accurately 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 the 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 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 ^[1] 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 numbered 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 Record Sheets

Various charts are available and the particular choice of chart used depends on operator preference. A complete dental record is required for diagnostic and therapeutic purposes, as well as for medico-legal reasons.

Also see:

Dental Terminology

Dental Chart Notation

Modified Triadan System

References

↑ Floyd MR. (1991) The modified Triadan system: nomenclature for veterinary dentistry. J Vet Dent 1991;8(4):18–19.

Endorsed by WALTHAM®, a leading authority in companion animal nutrition and wellbeing for over 50 years and the science institute for Mars Petcare.

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[1] Floyd MR. (1991) The modified Triadan system: nomenclature for veterinary dentistry. J Vet Dent 1991;8(4):18–19.

[1]

@@ Line 1: / Line 1: @@
-==Recording==
+{{OpenPagesTop}}
-The information resulting from the examination and any treatment performed needs to be recorded.<br><br>
+[[File:Dental charts.jpg|right|200px|thumb|Examples of dental charts<small>''© Lisa Milella 2013''</small>]]
+<br><br>
+The information resulting from an [[Oral Examination - Small Animal|oral examination]] and any treatment performed needs to be accurately recorded.<br><br>
 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 post-treatment discharge – to inform the owner of the condition of the [[:Category:Teeth - Anatomy & Physiology|teeth]] and of the treatment performed
-*At any time or by any person in the practice – for information related to the mouth at a specific date.
+*At any time or by any person in the practice – for information related to the [[Oral Cavity Overview - Anatomy & Physiology|mouth]] at a specific date.
 <br>
 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.
+A Dentalabel® is one example of a dental chart. It provides a simple way of recording most findings and treatments. However, it is only a chart and needs to be supplemented by clinical notes, [[Intra-Oral Radiography - Small Animal|radiographs]], etc. to form a complete dental record.
 <br><br>
-Most charts make use of the modified Triadan system <font color ="red">(Floyd, 1991)</font color> where each [[:Category:Teeth - Anatomy & Physiology|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.
+Most charts make use of the [[Modified Triadan System|modified Triadan system]] <ref>Floyd MR. (1991)''' The modified Triadan system: nomenclature for veterinary dentistry.''''' J Vet Dent'' 1991;8(4):18–19.</ref> where each [[:Category:Teeth - Anatomy & Physiology|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 numbered 09.
 <br><br>
 <center><big><b>Modified Triadan System – Quadrant Numbering</b></big>
@@ Line 38: / Line 40: @@
 </center>
 <br>
-==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.<br><br>
+===Dental Record Sheets===
-'''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. <br>
+Various charts are available and the particular choice of chart used depends on operator preference. A complete dental record is required for diagnostic and therapeutic purposes, as well as for medico-legal reasons.
-'''Palatal''' – surface of the tooth towards the palate<br>
-'''Lingual''' – surface of the tooth towards the tongue<br>
-'''Labial''' – surface of the tooth towards the lips<br>
-'''Buccal''' – surface of the tooth towards the cheeks<br>
-'''Occlusal''' – surface of the tooth facing the opposite jaw<br>
-'''Interproximal''' – surface between two teeth<br>
-'''Mesial''' – surface of the tooth towards the front mid-line<br>
-'''Distal''' – surface of the tooth away from the front mid-line<br>
-'''Apical''' – towards the root<br>
-'''Coronal''' – towards the crown<br><br>
-==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
 <br><br>
-Ensure that all abnormal findings are recorded on the chart and, where possible, give details including location, severity, size (mm) & direction.
+<b><big>
+Also see:
+:[[Dental Terminology]]
+:[[Dental Chart Notation]]
+:[[Modified Triadan System]]
+</big></b>
+==References==
+<references />
+{{Lisa Milella written
+|date = 21 October 2014}}
+{{Waltham}}
+{{OpenPages}}
 [[Category:Oral Examination]]
+[[Category:Waltham reviewed]]

Difference between revisions of "Dental Recording"

Latest revision as of 13:53, 2 November 2014

Dental Record Sheets

References

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