1 | P a g e

} {

- used issystem notation Dental -for: associating information, a specific tool

and it's commonly used in the pediatric

field.

- Universal Sys. :

We use letters from (AT) for primary teeth - Maxillary teeth from (A-J)

- Mandibular teeth from (K-T)

We use Numbers from (1 -32) for permanent teeth - Maxillary teeth from (1-16)

- Mandibular teeth from (17-32)

2 | P a g e

- Palmer Sys. :

Refers to teeth by 2 characters:

1. a symbol to discriminate in which quadrant the tooth is found and the number indicates the position from the midline

2. a letter for >>> Primary teeth from (A-E) >>> Permanent teeth from (1-8)

- FDI Sys. (International system):

This is the system that we use, and its used by dentists to associate information about teeth (on conferences or internationally b/t dentists. Its best to use this system because its well known)

- The FDI uses a 2-digit numbering system:

The first one (the number on the left) is to indicate the quadrant. So for the permanent teeth we use (1,2,3,4) and for the primary teeth

we use (5,6,7,8).

The second one (the number on the right) is to indicate the tooth. We use. (1-8) for permanent teeth, (1-5) for primary teeth.

3 | P a g e

>>>> slide (6):

This is a table that shows you the teeth in different systems (Palmer/

Universal/FDI)

For example lets take the upper right central incisor in deciduous dentition:

In the universal notation it will be E In the palmer notation we do an angle for upper right A_| In the FDI it will be 51 (FIVE ONE) because we need to obligate

the quadrant number and the tooth number >>>> we should not say

(fifty one) that is not acceptable.

DENTAL CHARTS :

This is the dental charts and this is what we use in the clinic. You will

be writing in these boxes.

>>>>> Each one of these boxes indicates a tooth & its surface.

Slide (8):

Look for the central incisor, it's a permanent tooth.

In FDI notation system we name it (11)

In the Universal system (8)

In the Palmer system ( 1_|)

4 | P a g e

Slide (9): (upper arch)

-Upper right 6 ----------- FDI (1 6)

- The tooth which is in front of the right 6 is a primary tooth (upper

right 5) 2nd

pri. Molar ----------- FDI (5 5)

- We have remnant of the D ------------ FDI (5 4)

Then we have: 53, 12 (per. Lat. Incisor), 11, 21, 22, 63, 64, 65, 26.

Slide (10): (upper arch)

55, 54, 53, 52, 51, 61, 62, 63, 64, 65.

Slide (11): (lower arch)

85, 84, 83, 82, 81, 71, 72, 73, 74, 75.

We can include supernumerary teeth in the notation system by

using a symbol (S).

If we have supernumerary teeth we have to indicate their presence

apart. We say that we have a supernumerary tooth, and then in our

diagnosis section we give more details about the type of this tooth.

5 | P a g e

What the meaning of record keeping?

It's the thing that we are supposed to fill in the patients chart, how to keep them in the clinic, what kind of information should we be writing on

them and how we should be consistent in writing between visits.

- A record includes all important details of the patient i.e. it identifies the

patients ID.

Importance of record keeping:

1. Identifies the patient, it indicates a high quality

curve. We have a specific record for each patient. If

you get it at each time the patient comes in, that

indicates that you are doing a very excellent job.

2. Gives details you need to offer treatment (e.g., MH, DH, X-RAYS)

3. Helps remember details and saves them for future appointments (e.g., size of SCC )--- stainless steel

crown used for children

4. Facilitates comprehensive treatment and prevents any complication that might happen (e.g., the first

time the kid was not cooperative , confused , he was

screaming, shouting & not complied for the treatment

so in the next time you read this in the chart you will

know how to deal with him )

5. Continuation of care by other dentists. 6. Medico-legal issues >> this means if the patient

wants to complain about you, the chart will be

requested by the court. The chart should have all

details so make sure that you are writing correct

information in it, but not against you.

7. Teaching and research. 8. Forensic issues. If you have a charting of teeth, and

you indicate in this chart that the patient is having a

specific lesion or developmental anomalies, by this

you can tell who the person is from a specific

6 | P a g e

appearance of teeth (hypo mineralization defect,

occlusion of the teeth class 1-2-3, developmental

anomalies). If these details was in the chart and the

patient for example was in Tsunami, an earthquake,

war (it happened a lot) so you can identify him by his

teeth.

Records used in pedo. clinic at JUST DTC :

The patient gets examined at pedo clinic, the exam form is filled

X-ray is taken

Some treatment is performed

Extension sheet is filled with treatment details

The exam and extension sheet with the x-ray are taken to the

receptionist and are filled there by labeling with a number e.g.,

45061.

Files are stored and saved on the 1st floor

You may ask for the patients file by giving the name, through computer, the number may be obtained and the file is found.

Components of dental record : 1. File number, name, age, sex, DOB, address, tel. number,

school.

2. Consent form.

3. MH sheet.

4. Dental exam sheet extension sheet.

5. Diet sheet (its a special sheet that we give to the pt. and fill regarding the diet so we determine the cariogenisty of the diet).

6. Radiographic record.

7. Photographic records and stone models

8. Cephalometric tracing sheet. 9. Trauma sheet.

Other details include (personal details, dates, chief complaint, MH

should be rechecked every visit in case any thing changed, conducted

examination, RG, any communication with the patient or any details

about the patient & the treatment)

7 | P a g e

Baum's molar relationship Flush: when the distal of the upper & lower molar are at the same

level.

Mesial step: when the distal of the lower molar is mesial. Distal step: when the distal of the upper molar is mesial.

Angle's molar & canine relationship Class I: the molar relationship of the occlusion is normal, the MB

cusp tip of upper molar is placed in MB groove in lower molar . Class II: (overjet), the upper molars are placed not in the

mesiobuccal groove but anteriorly to it. Class III: (negative overjet) the upper molars are placed not in the

mesiobuccal groove but posteriorly to it

End of part 1

Forgive me for any mistake Done by : Hana'a Ajour

8 | P a g e

The same is here, 22 means: permanent lateral incisor, 62 means

primary later incisor. Here in the lower, either 3 or 7 (referring to the left

of the patient) and here either 4 or 8 (referring to right of the patient)

The numbering is done when you are examining the patient because most

of our patients come to us in the mixed dentition stage so we have

primary and permanent teeth and we have to differentiate between them.

Lets talk about symbols in charting

* This patient is probably 9-10 years old. So 7 is not erupted at this age.

We did a horizontal line __ here to indicate that 7 isnt present. not

erupted

*on 16 we have a black dote which means there is a filling.

*on 46 we have an empty circle which indicates presence of a cavity on

the occlusal surface. If the cavity is moving to the mesial >> the circle

will be on both occlusal and mesial surfaces, so its an MO cavity .

If you fill the cavity, just fill the circle.

*on 55 we have a cross which means that it was extracted by a

dentist and not exfoliated.

*This oblique line means that the distal needs to be extracted , once its

extracted we will draw the other line .

9 | P a g e

*Here C indicates that there is a crown on 54

*Nothing on 53 and 83 which indicate that they are sound

*This () on the tooth means that there are caries

As we can see:

There are incisopalatal caires , And occlusodistal ones

* + means remaining root

This sheet differs among universities and counties.

Diet sheet

We have the Arabic form in our clinics

Its filled by the patient whatever he eats for breakfast, lunch and dinner

in 3 sequential days, and one of them should be a holiday. There is a

space here for snacks between meals. So in Jordan, holidays are on

Fridays and Saturdays so it can be: Wednesday, Thursday and Friday.

In this sheet we arent looking for a healthy diet, we are focusing on food

containing sugar, although a healthy diet indicates how healthy your teeth

are.

Radiographic records

This sheet has information about radiograph that is done for the patient,

code of them in the clinic and who

makes these radiographs (operators

name).

E.g., look to the figure, the patient on 12-

3 has done 2 bitewing radiographs and

an OPG.

11 | P a g e

Then you write the details on the Radiographic report. It contains

information about the:

//views taken > (periapical or periapical with angle, etc )

//caries > this is where you indicate the

teeth and surfaces involved with caries

For example: 46 O > means occlusal, 75

MO > mesiocclusal, 64 DO, (B) > for

buccal,( L )> for lingual ,and finally (I)

for the incisal edge

//periapical involvement > such as

periapical

//Bifurcation involvement

// Root resorption

// missing teeth

// supernumerary teeth > we write the supernumerary tooth and its shape

// other findings > such as a cyst.

Photographic records :

Photos are taken, saved on TVs, and filed. Usually they are extraoral or

intraoral.

- Please check the example in the slide

11 | P a g e

Diagnosis: can be dental caries, gingival problems (abscess, chronic

marginal gingivitis), enamel hyperplasia, anything related to occlusion

(class I or class II malocclusion). But we cant say poor hygiene because

its a problem in the patient not diagnosis.

Diagnosis is when you give a name for a specific condition, dental or

medical term.

A problem is something that we dispose the patient from.

Treatment plan

This is what you have to learn in next lecture, Inshaallah.

# Usually theyre separate plans in the each visit, and we indicate what

we are going to do (your plans in the future visits) > so its helpful in

explaining for the parents.

# Usually we treat each quadrant on a separated visit start with the upper

quadrant >> upper RT , upper LF , lower LF and finally Lower RT

# for example , in the 1st visit I will do examination, 2 BW, OPG then I

will give oral hygiene instructions, diet advices, fluoride gel application.

Then for 16 I will place a fissure sealant and for 55 a Preventive resin

restoration.

Notice that there are long details about the patient and they are time

consuming, but its only done in the 1st visit, so in next visits you will

have to read the chart and complete your treatment, only.

Now in next visits you have to record the treatment preformed in an

extension sheet which contains:

//Chief complain > why did the patient come today? To check up? To

complete a treatment? or for an emergency?

//Medical history> just like a type of assurance.

//who was present with the patient > mother, father, uncle, grandmother,

grandfather, etc

//Treatment done

12 | P a g e

// behavior of the patient in the clinic > its specific for patients behavior

Back to slides: patient refused to sit on the chair and sat on mothers

knee and we have to force the pt to open his mouth

//next visit > what you attend to do in the next visit according to your

treatment plan.

This is an example here (back to slide), chief complain : food caught

accumulation between lower Rt molars due to presence of a cavity.

medical history : nil changes nothing changed since the last

examination , Treatment done : 2 bitewing radiograph and we found

mesial caries on 85 and on 75 and incipient caries on 74 , so what we did

in the last visit was : local anesthesia , 1 carpule , ID block , we did an

amalgam filling on the distal surface of 85.

Beh: good + needs a great explanation of all the treatment done.

N.V: restore 75mesially with amalgam and done with it , review in 6/12

and take a bitewing , check 74 distally for the incipient lesion.

How is information recorded ?

>You have to document the patients record immediately at the time of

appointment or soon then after (on same date). So once the patient leaves

the clinic, you write immediately and this is the best times to write your

notes.

>The entries must be in a terminological order according to date and

should be in sequence, so 1st you give local anesthesia, then you do the

filling then you do the extraction , so they should make sense when you

read them.

>They have to be accurate and concise , which means that you have to

give accurate information in consistent, so each time I read the

information : the chief complain , MH , Tt done ,etc should be the

same and should be clear and obvious for you , patient amd other

specialists

>Correction shouldnt remove regular information. So if you want to

make correction, you have to sign on it and you will be responsible about

13 | P a g e

that, but if you make a mistake while writing you can use a corrector and

dont sign on it.

> Should be written in couch and should be objective and in unemotional

manner, that means if the patient gets you upset because of his or her

parents attitude, so whatever you are feeling you should write the details

such as: I examined the patient and the father got upset and refuses the

treatment Plan, and you can add between brackets the father said

unrespectable words, and so on.

How long do we keep the pt. record ?

Ideally for adults, we usually keep it for 7 years after the final visit. For

example, last time he came was on 2003, we keep the chart until 2010,

and then we can get rid of it because of space limitation. For children

records must be kept until the age of 25.

Its always your job to keep the patients privacy and confidentiality. For

example, if the patient has separated parents or parents cant stop fighting

in front of you, or if your patient has a disease such as AIDs or Hepatitis

you shouldnt share that with your colleagues. You will swear on that in

your graduation ceremony to keep confidential, because this shows how

high moral you are.

The patient trusts you with fine details and they expect you to keep their

privacy, so you cant share your cases on clinic with your students even

for teaching purposes without patients agreement.

A NEAT AND PRECISE CHART MEANS A NEAT AND PRECISE DENTIST

A LOUSY CHART MEANS A LOUSY DENTIST WHICH MEANS ZERO IN MY

CLINIC!!

End of part 2

Made by: Farah Salem

14 | P a g e

Lecture (2) summary: -Notation systems and dental charting:

A Dental chart: is a chart of teeth according to a selected notation system so all lesions reported on the chart. (Each of the boxes indicates a tooth and its

surface on the chart sheet). :Universal Sys-

Letters from (A T) are used for primary teeth * - Maxillary teeth from (A-J) - Mandibular teeth from (K-T)

* Numbers from (1 -32) for permanent teeth - Maxillary teeth from (1-16) - Mandibular teeth from (17-32) - Palmer Sys. :

Refers to teeth by 2 characters: 1. a symbol to discriminate in which quadrant the tooth is found and a

number indicating the position from the midline 2. a letter >> primary teeth from (A-E) > permanent teeth from (1-8)

- FDI Sys . (International system ) :

- The FDI uses a 2-digit numbering system: *the first one (the num. on the left) is to indicate the quadrant so for the permanent teeth we use (1 to 4) & for primary teeth (5 to 8).

*The second one (the num. on the right) is to indicate the tooth. We use (1-8) for permanent teeth, (1-5) for primary teeth.

**We can include supernumerary teeth in the notation system by using a symbol ( S ).

Record keeping in pediatric dentistry: - Records include all important details of pt. ** -Importance of record keeping:*identifies the patient *gives details you need to offer treatment *helps remember details and save them for future appointments & facilitate comprehensive treatment & to prevent any complication that might happen &continuation of care by other dentist *medico-legal issues *forensic issues *research issues. - Components of dental record:*file #, name, age, sex, DOB, address, tel #, school.*consent form *MH sheet *dental exam sheet extension sheet *diet sheet *radiographic record *photographic records and stone models *cephalometric tracing sheet *trauma sheet.

-Angle's molar & canine relationship:

**Class I **Class II: (overjet) **Class III: (negative overjet). - chart symbols:

Unerupte , remaining root, cavity , crown, filling, extracted, need extraction, caries

15 | P a g e

Diet sheet :we are focusing on food containing sugar although healthy diet

indicates how healthy your teeth are.

Radiographic records: This sheet has information about radiograph that is

done for pt, code of them in clinic and who makes these radiographs

(operators name)

Radiographic report: contains information about //views taken > //caries >

//periapical involvement > //Bifurcation involvement // Root resorption //

missing teeth // supernumerary teeth > // other findings.

Photographic records: Photos are taken, saved on TVs. and filed. Usually

they are extraoral or intraoral.

Diagnosis: Diagnosis is when u give a name for a specific condition.

Treatment plan: (your plans in the future visits "each visit we treat a

separated quadrant ").

Extension sheet: details of the treatment performed. //Chief complain

//Medical history//who was present with the pt//Treatment done

// behavior of the pt. in clinic //next visit >

How is the information recorded? > Immediately at the time of appointment

> order according to date and should be in sequence > they have to be

accurate and concise >Correction responsibility > should be written in couch

and objective and in an unemotional manner.

How long do we keep the pt. record for? Adults, for 7 years after the final

visit. For children until the age of 25 years old.

*Past year Q about this lecture: ^_^

Q1- the components of the treatment plan that must appear in all treatment plans are

a- preventive, restorative and recall components

b- Preventive, recall, and management of developing dentition components

c- Preventive, management of developing dentition, and restorative components

d- Preventive and recall components

e- None of the above

Q2- which of the following is / are a component of the diagnostic method

a- history taking

b- Radiographic examination

c- Tenderness and mobility

d- Laboratory tests

e- all of the above

Done by : Salam Al-Batayneh