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While traditional dental charting systems have served the profession well for generations, they do have several limitations and in some respects, electronic versions of these records may even have increased the associated risks. This article looks at the importance of recording a variety of tooth surface features that traditional dental charting grids were never designed to capture, and how this can best be achieved.
Cavities
The conventional dental charting grid incorporating the familiar designs shown above was designed to record which teeth were present or absent, to facilitate the recording of the site and extent of dental decay, and to provide a diagrammatic representation of the treatment to be carried out. It has been adapted in various ways over the years since it first appeared, often to include periodontal records that integrate the charting of both hard and soft tissues.
When carious cavities were drawn freehand on a standard charting grid on a paper record card, it was possible – at least in theory - to achieve a fairly accurate representation of the extent and shape of the cavity, and which surfaces of the tooth were involved. In practice, however, a clinician would usually call out the clinical findings as the teeth were being examined and a chairside assistant would record this information by means of entering standardised symbols on a charting grid. In many cases the sophistication and accuracy that was possible (and desirable) was not always achieved, especially in busy surgeries where this process was carried out more quickly.
Meanwhile, computerised records have sometimes compounded this lost opportunity by representing every broad type of cavity (for example, a mesioocclusal cavity or ‘MO’) in exactly the same way, using standardised computer graphics irrespective of the size and shape of the actual cavity.
Conduct and unfitness to practise
Cases being considered by the IDC under the terms of the Dentists Act 1985 fall into two categories. The first of these is alleged professional misconduct which, in this context, is defined as a serious falling short, by omission or commission, of the standards of conduct expected among dentists. The other category is unfitness to
engage in the practice of dentistry by reason of physical or mental disability.
Where there are concerns about a dentist’s clinical treatment of a single patient, this will be dealt with as a conduct issue but, as we have seen above, such concerns may widen to include the standard of the clinical records.
Early caries
The era of minimum intervention highlighted the inadequacies of the conventional charting grid, because of the difficulties of distinguishing between a carious lesion that required restoration, early (white spot) lesions as well as areas in the process of decalcification or remineralisation.
Being able to monitor the stage of progression of these lesions is central to the minimum intervention approach. Dento-legally it is important to be able to demonstrate;
a) that the clinician had identified and recorded the presence of the lesion
b) that the clinician had correctly identified the status and extent of the lesion
c) that the clinician’s decisions for the management of the lesion were appropriate to the findings at (a) (b) above
d) that the clinician subsequently monitored the progression of the lesion and took appropriate steps to manage it, including any relevant advice to the patient in terms of oral hygiene, diet, topical fluoride etc.
If all the records show is the familiar symbol of a cavity on a charting grid, the question might well be asked why the cavity was not treated as soon as it was identified. Trying to persuade a court that, perhaps months or years later, you recollect clearly that the lesion was actually not a cavity at all, but an early white spot lesion or a remineralising tooth surface, will be an uphill struggle – especially if (as is often the trigger for cases of this nature) the patient has been seen by a second dentist who has diagnosed numerous areas of untreated decay.
Tooth surface loss
Another familiar clinical challenge is tooth surface loss through erosion, abrasion and attrition, and especially, situations where two or more of these factors are working in unison. Here, study models are often a useful adjunct to capture the all-important third dimension in the clinical records of the damage to the teeth in question. But here again, the traditional charting grid is far from ideal as a tool for recording tooth surface loss of this nature, at least not with the necessary degree of accuracy.
Wear facets, chips and fractures
When located on occlusal surfaces, incisal edges, cusps and restorations these changes do not always need much in the way of active treatment, but they do need to be recorded. In the older patient with a heavily restored dentition they may simply reflect a lifetime of wear and tear, but in adult patients of all ages they may be indicative of occlusal problems, bruxism or parafunction. In such cases, these clinical findings are part of the diagnosis and the records would be incomplete without them.
Undermined cusps
In the heavily restored dentition, weakened and undermined cusps of posterior teeth are a fact of life. But there are occasions when the survival of the last remaining cusp is closely linked to the prospects for the survival of the tooth itself. Identifying ‘at risk’ cusps and recording them in a meaningful and reproducible way, is an important part of contingency planning in restorative dentistry.
Pits and fissures
The conventional charting grid is not ideally designed to differentiate between smoothsurface lesions and pit/fissure involvement. For example, on the buccal aspect of a lower first molar- is the lesion at the cervical margin, or in a buccal groove, or in a buccal pit? A ‘freehand’ charting on a paper record does have the capacity to make this distinction but irrespective of whether paper or computerised records are used, this level of detail is rarely captured.
Cracks
As our patients are keeping more of their teeth later into life, with many of these teeth being heavily restored, clinicians are encountering more cracked teeth. Some of these are hairline cracks that would be difficult to detect without transillumination. Most cracks simply need to be kept under observation, but this is difficult to do unless and until their presence has been recorded in a way which facilitates a meaningful comparison over time.
Surface characteristics
Discolouration, translucencies and opacities are all important characteristics of the appearance of a tooth, that might be relevant to the question of whether or not to restore it, and if so, in what way.Very often, the question that is asked dento-legally is that of whether a tooth was treated appropriately, or indeed, whether a less interventive treatment approach might have avoided the problem that has given rise to the complaint or claim. Clearly, neither the charting grid, nor x-rays, nor study models, are designed to record these important aspects of the status of a tooth, tooth surface or restoration.
A solution
It has been said that a picture is worth a thousand words, and this may well be the case in some of the situations which have been described here. Digital photography is much easier and more convenient than the timehonoured expedient of photography using conventional film. It can transform the quality of clinical record keeping by capturing details that would be difficult or impossible to record in any other way. Clinical images also make the challenge of storage, and communicating with patients and professional colleagues, very much easier. Once they become integrated with other electronic records (text and radiographs), these images can provide a readily accessible, permanent confirmation of the physical appearance of a tooth or tooth surface at a moment in time.
Similarly, the ‘narrative’ of our own records – written or typed at the time ‘freehand’ - can often come to the rescue by filling in the gaps that even a picture could not address. You need to ensure that you have given yourself the best possible chance of remembering what you are looking at in the patient’s mouth today, and if in doubt, confirm in writing anything that would otherwise be unclear.
Our records are often the only means at our disposal for reconstructing the information that was available to us at the time we were actually treating the patient. Not unusually in dentolegal cases, many months or years will have passed between the time of treatment and the moment when you need to piece together what actually happened.
The reconstruction process is not easy, but it is certainly made much easier if you have access to all the raw materials for the exercise. The conventional charting grid may no longer cover all the eventualities that today’s clinician might face, but with a bit of imagination there are many ways in which you can effectively overcome such limitations.
Based on an article featured in Riskwise Ireland 21