You're at the end of a long day, sit down to sort your notes out and realise that you've somehow forgotten to update the dental chart on your software. Was it UR6 or UR7 that you discussed putting a crown on? Or perhaps you're looking into an oral cavity, dental mirror in hand, calling out a chart to your nurse for them to turn around and say there couldn't be a crown on UL6 as it the multi-rooted tooth is missing on the existing chart. How can you form an appropriate dental treatment plan if the baseline information is not correct?
If any of the above sounds familiar then you are not alone.
Brown and Jephcote conducted a 2017 audit, where they looked at dental charts conducted by fourteen UK based dentists and out of 1128 patients. The basic findings showed a staggering 44% of the dental charts presented were inaccurate. Notable issues identified included; the incorrect number of teeth recorded, dental restorations recorded on the wrong tooth (both composite restoration and amalgam restoration) or they were indeed entirely missing from chart.
At dental school we are taught how to chart early on and get in the flow of doing so well before graduating but clearly something is going amiss in practice.
So lets get down to the basics.
What is dental charting?
Charting was first introduced into dentistry as a method of recording a patient's dentition in their notes in shorthand to help build a dental care plan, provide a valuable tool in forensic tracing and most importantly, establish the patient's oral health status, monitor their dental health and identify and oral health issues.
It should be updated at every dental examination and can be completed on paper or digitally on dental charting software. These are centred around a grid chart of the mouth. Current charting systems facilitate recording health or decay on individual tooth surfaces outlined below:
- Mesial surface
- Distal surface
- Buccal surface/Labial surface
- Lingual surface/Palatal surface
- Incisal surface/Occlusal surface
It denotes where there is a healthy tooth, any obvious anomalies such as a missing tooth, an existing restoration or decay, and allows you to specify which findings apply to the tooth crown and the tooth root.
Globally, there are different notation systems that the grid may be presented in, which should account for tooth type, ie differentiating between a permanent tooth and deciduous tooth. The four most common are:
Alphanumeric notation
This system splits the mouth into four quadrants - upper right (UR), upper left (UL), lower left (LL), lower right (LR)
Permanent teeth are number 1-8 and deciduous teeth are a-e, moving backwards from the midline, ie 1 being a central incisor through to 8 being a wisdom tooth/third molar
Palmer notation
This is a numerical and sign based system which uses the same primary and secondary teeth markers as alphanumeric notation.
FDI world dental federation notation
A double digit system where the first reflects what quadrant the tooth is in (UR=1, UL=2, LL=3, LR=4) and the second denotes which tooth in that quadrant similar to Palmer notation. For example, 36 is the lower left 1st molar tooth. Deciduous teeth are reflected by the first number (UR=5, UL=6, LL=7, LR=8)
Universal numbering system
Teeth are numbered 1-32, starting on the upper right going clockwise. For example, 18 is the lower left 1st molar.
Why is dental charting important?
Whats the big fuss about charting then? In today's environment of minimal invasive dentistry, focused on prevention based oral health instruction, it is imperative that we have an accurate record of a patient's dentition to aid clinicians in spotting any unhealthy behaviours and trends, which in turn helps patients to maintain a healthy mouth.
Forensic odontology is a refined science and dental charts are a highly valuable tool of forensic significance. They are used for human identification and ageing during post mortem, often when other identifiable features are not possible to be used, as the tooth structure and indirect restorations are very resistant to damage.
In addition, the increasing climate of litigation means that having precise, organised and easy-to-read record forms the basis of a solid defence. Most importantly, the GDC requires dentists to maintain complete and accurate dental records; the baseline chart of a patient being a key component of this.
Periodontal charting
For all patients at the their regular dental examination, we must conduct a basic periodontal examination (BPE) which shows by sextant where there may be gingival inflammation as evidenced by bleeding scores and epithelial attachment loss as evidenced by increased probing depths. If a patient has two regular checkups with a code 3 BPE or they have a code 4 BPE we must complete the 6 point pocket chart (6PPC).
A 6PPC is a recording of the periodontal pocket depth using a ball ended dental probe. It gives us a visual assessment of the epithelial attachment loss occurring in periodontally compromised patients. Proper charting also allows us to record furcation involvement, mobility of teeth and recession. Combined with dental radiography, to show the loss of bone support around the teeth, we can come up with a periodontal health diagnosis, inform the patient of their periodontal status and in turn form an appropriate treatment plan, on the correct treatment pathway.
Toothwear charting
The Basic Erosive Wear Examination (BEWE) can provide a useful metric to chart the amount of toothwear present in each sextant of the mouth. Similar to BPE you will be guided by the most severe tooth in a sextant. Both these charts are integrated into our templates available on the template store.
Tips on how to improve your charting workflow
Check how to chart on your software
This one sounds basic but every system operates differently and early on in your career you may be exposed to different software systems that all work slightly differently and make reference things in different ways. For example, tooth wear might be phrased as tooth surface loss, surface worn, fractured tooth or TSL. When you start using a new system you should have a proper induction by your practice but youtube can also be a brilliant resource for getting ahead of the game.
Have a chat with your nurse
Every dentist will work slightly differently. It can be helpful to have a sit down with your nurse when you first start working with them just to check their familiarity with the charting system and how you like to do it. Everything we do in dentistry is team work and when you are calling out your chart you want to be comfortable that you both know what order things go in. It is worth having a systematic approach and always starting in the same place. During mixed dentition, it may be an idea to chart all the permanent teeth in order and then all the deciduous teeth.
Double check your chart
Once you've established that you and the nurse are on the same page, come up with a system to ensure you get another check in. This may be by calling out the dental chart during your oral examination and then asking the nurse to repeat it back to you, or even having a look after completing each quadrant.
Free up your time
Using Kiroku helps save crucial appointment time and our template format allows you to ensure you hit all talking points and checks. This means that you will ensure that you can spend your appointment time checking the correct charting as you know you won't be spending the time deleting bits of templates or writing everything out freehand.
As dental professionals we are held to high standards of record keeping and ensuring your dental charts are as accurate as possible helps to uphold this GDC requirement.
