keeping thorough dental records is very important than you may think , it provide invaluable data to future students and practitioners , save you from litigation , share and spread education , unleash the power within....dental records

1. Prof. Dr S. P.S Sodhi
Principal /Professor & Head
Department of Oral & maxillofacial Surgery
Dasmesh Institute of Research
& Dental Sciences, Faridkot

3. All individuals are unique

4.  Dental evidence played a
vital role in the historical
case of identification of
Adolf Hitler
 Dental remains found on
Hitler's corpse were
matched with his dental
records in 1945

5. ROLE OF DENTAL PROFILING
IN PERSONAL IDENTIFICATION
 Dental profiling is used not only to
establish the identity of an
unknown individual, but also to
confirm the identity of a known
person, which was done in cases of
Saddam Hussein, Muammar
Gaddafi, Osama bin Laden and
Beant Singh former Punjab CM
whose body was identified by his
denture ( Prepared & Identified by
Dr.Bakshi).

6. HISTORICAL ASPECTS
• 49 A.D - Agrippina, wife of Claudius-Roman emperor, identified the body of
her husband’s divorcee Lollia Paulisa
• 66 A.D- Sabina, Nero’s mistress killed Nero’s wife
• King William – 1066AD first to use bitemark for identification
• Earliest identification from teeth is in 1775 by Paul Revere
- Paul Revere made a silver bridge for one man and he was killed in a
revolutionary war (Body was in mass grave identified by his bridge work)
• India 1199 AD - Rathore Raja of Conouj, Jai Chandra was recognized by his
false anterior teeth, after he was beaten and killed in a battle
• 1837 – Edwin saunders established the eruption sequence

7. FORENSIC ODONTOLOGY
Forensic Odontology or Forensic Dentistry is the
proper handling, examination and evaluation of
DENTAL EVIDENCE, WHICH WILL BE THEN
PRESENTED IN THE INTEREST OF JUSTICE.

8. • plays a vital role in
forensic investigations
by providing necessary
information in the form
of adequate dental
records
Dentists
• Especially when the
availability of other
evidence/remains is
scarce
Evidence
• Awareness
minimal
Irony

9. A recent study –
only 38% of the
dentists in
Rajasthan were
aware of the
importance of
maintaining
dental records.
62% of the dentists did
not maintain any form
of patient record.
Asteka
r et al.
Among dental
practitioners
in Chennai,
it was found
that 21% did
not maintain
any form of
dental records
Only 12%
maintained
complete
dental
records
Preethi
et al.

10. Every practicing dentist has a legal
duty, as in keeping some sort of record
of each patient for whom they are
providing the dental care
Dentists & patients forget
but
good records remember
J Forensic
Dent Sci.
2011 Jul-
Dec; 3(2):
63–66.

11. DENTAL RECORDS
• Comprehensive and accurate records are a
vital part of dental practice.
• Good record keeping is fundamental for
good clinical practice and is an essential skill
for practitioners.
• Uniformity in patients record treatment is
an important prerequisite for optimal oral
health.
• The dental record should reflect accurately
the interaction between the clinician,
patients and related services.

12. WHAT IS THE NEED FOR RECORD KEEPING ??
• The primary purpose of maintaining dental records is to deliver quality patient
care and follow-up.
• For good clinical practice
• Conducting clinical trials
• To promote teaching & Research
• Evidence against litigation
• Case review & Referral purpose
• Historical purpose
• Serve as the basis of accreditation

13. BENEFITS OF RECORD
KEEPING• Care for the patient
• Means of communication
• Defense of allegations of malpractice
• Aid in the identification of a dead or missing person

14. POINTS TO BE CONSIDERED
• All intra-oral and extra oral findings should be
recorded, the method may be standardised using
diagrammatic charts
• All the necessary clinical details including the status of
non lesional areas should be mentioned

15. POINTS TO BE CONSIDERED
• All the investigation details
(photography, casts, models, lab
findings, Radiography, Biopsy ,
Haematological) should be
mentioned
• Finally at the end short summary
of the observations, findings and
comments pointing towards
differential and definitive diagnosis

16. LAWNEY ‘S SIMPLE TEN-STEP
PROCEDURE TO ENSURE ADEQUATE
DATA
• Use a consistent style for entries
• Date and explain any corrections
• Use single-line crossout
• Do not use correction fluids.
• Use ink
• Write legibly
• Express concerns about patient needs
• Never write derogatory remarks in the
record
• Document fully
• Only use accepted abbreviations for
treatments
• Collate documents
• Maintain a chronological order

17. Patient records
Business records
Drug records

18. Recorded in ink and not in pencil legibly
/electronic format
Date of every patient visit
entered in a chronological
order
General patient
information –
age, gender,
birth date,
place of
employment,
contact
information i.e.
telephone
numbers and
address & any
referring party
Chief
complaint, past
dental,
medical, family,
drug histories
and allergies
need to be
updated
regularly and,
in case of
children, the
immunization
status.
Complete recording
patient’s case history form
Clinical and
radiographic
findings,
diagnosis,
proposed
treatment
and
prognosis
Copies of
test results,
instructions
for home
care, patient
follow-up
and recall
examination
s, fees
charged and
referrals

19. Dentist is ultimately responsible
for the patient’s chart
Adequately label and date all
diagnostic aids including
radiographs, study models,
photographs etc.,
Established terminology,
symbols and abbreviations
should be used
All entries should be signed or
initialled by the treating
clinician
Informed consent forms with
patient signature for invasive
procedures, sedation etc.,
should be taken
Signature of the patient on
refusal of treatment advised
by clinician
Record should be objective in
nature

20. Details of Billing with date & amount
Copies of claims forms submitted by
the patient
Information related to name, address,
nature of the laboratory services used
& laboratory charges, scheduling of
appointments etc

21. Any mistakes in the records
should be corrected with a
single line drawn through the
incorrect material in an
honest, open manner
All communications with the
patient, including emergency
telephonic consultations,
should be recorded
If a patient is dissatisfied, all
communications should be
recorded including the
problem, the attempt to deal
with the problem and the
solution to the problem
If a patient wishes to
discontinue treatment, a
note of it should be made in
the patient’s record along
with the reason
Classify all patient files into
either active or inactive

22. Not
documenting
health history
clearly or
failure to
update it
regularly
Failure to
document
informed
consent or
refusal
Not recording
the treatment
plan

23. Date and
method of
prescription/
administratio
n/ dispensing
of drug
Name,
strength,
quantity and
form of drug
Directions for
use of drug
Condition
being treated
and/or
dental
treatment
provided

24. • Reason for visit to the dentist, which
includes the patient’s chief complaint/
and symptoms
Subjective
data
• Treatment options
• Prescribed medication
Objective
findings
• Diagnostic and therapeutic judgmentAssessment
• Treatment options
• Prescribed medicationPlans

25. COMPUTERISED DATA
• The data should be entered in such way that old information be
over written and new information can be added.
• The data should be encrypted & protected by a password
• There should be copy of the data available in the practioner’s
room in a read only format
• Backup system to retrieve the data should be tested from time to
time
• The right of the patient’s privacy, security and confidentiality
should be protected all the time

26. MAINTENANCE OF THE DENTAL
RECORD
• The files are then arranged in a way for easy
retrieval — usually in a lateral, open-shelf filing
system.
Colour Coding
• Many dental offices use a colour-coded filing
system for patient record files.
• Colour-coded labels — usually the first two
letters of the patient’s last name and active
date of treatment

27. MAINTENANCE OF THE DENTAL RECORD
Active and Inactive
• Most offices have two categories of patient records files:
(1) Active
(2) Inactive
• Active files hold the records of patients currently having their dental
care provided by the practice.
• Keep files of active patients on-site.
• Inactive patients are considered to be those who have not returned
for 24 months.
• Inactive files hold the records of patients who have been treated in
the office in the past, but are not currently under care in the office.
• These files are generally located in the office, but in a remote area.

28. CONFIDENTIALITY
• Confidentiality encourages open and honest communication,
enhancing the dentist–patient relationship, and encourages
respect for patient autonomy and privacy.

29. Protected from
any unauthorized
use or disclosure
even to family
members except
when required by
law or where the
patient has given
their express
consent, ideally
in writing
Stored in a
safe place
& never
left
unattende
d
For Electronic
Records
Login and
password
to access
data
Back up on
removable
medium

31. Retention of Records
American &
European
countries
• Record
maintenance
by dentists is
legally
mandatory
USA
• A National
database
keeps
track of
dental
records
Israel
• A central
repository
for dental
records of
all soldiers
However, No unified National or International repository of dental
records

32. Country/ organization Duration
Department of Health (DH) for
National Health Service (NHS)
organisations in England
Community dental records: 11 years
for adults and children or until the
patient is 25 years old
Hospital records: 8 years in adults
and until the patient is 25 years old
Provincial Dental Board of Nova
Scotia
2 years following treatment
completion
MCI regulations 2002 3 years from commencement of
treatment (Section 1.3.1
and Appendix 3)

33. Revised Dentists (Code of Ethics) Regulations – 2014
3.3.1
• Every Dental surgeon shall maintain the relevant
records pertaining to his out- patients and inpatients
(wherever applicable). These records must be
preserved for a minimum period of three years from
the date of commencement of the treatment in a
format determined by the Council or accepted as a
standard mode of documentation.
3.3 Maintenance of Dental/Medical records :

34. CUSTODY OF THE RECORDS
• Under lock & key, in custody of doctor concerned or in
MRD
• As per law, no specified time limit after which MLRs can
be destroyed
• Advisable to preserve all IP records for at least 5 Yrs &
OPD - 3 Yrs & MLR, indefinitely
• DIRDS destroys OPD/ IPD records after 10 yrs; NOT MLRs
[which are in custody of Department]
34

35. Forensic Uses of Patient Records
 The availability of contemporaneous and clear notes is essential in
forensic dental identification.
 If notes are incorrectly dated, it can complicate and even negate a
positive identification.
 When a request for records is received the entire record is useful,
including such items as laboratory prescriptions and study models.
 Many documented cases have used the unique pattern of the palatal
rugae recorded on an orthodontic study model to identify young
individuals with no dental restorations.

36. Individual Characteristics
 Size of tooth
 Shape of tooth
 Shape of root
 Placement of tooth
 Quantity of teeth
 Combinations of dental
work done:
 Crowns
 Extractions
 Bridge
 Fillings
 Root canals Various dental work

37. Comparison of AM &PM dental data
Based on Tooth morphology
, bony restoration, soft
tissue changes, fractures,
dental restorations, and
other pathology

38. Writing report &drawing conclusion
 CONFIRMS IDENTIFICATION – AM – PM match each other.
 PROBABLE IDENTIFICATION – data is consistent but can
not confirm identity.
 POSSIBLE IDENTIFICATION – explainable difference
between AM – PM.
 INSUFFICIENT INFORMATION – data is insufficient or
minimal.
 EXCLUDES IDENTIFICATION – data are clearly inconsistent.

39. Future Prospects ???

40. Future Prospects ???
UHID
Comparison
AM - PM
• Digital Bar-
coding
• Nano - chips
• RFID
Technology

41. Take home messages
 Doubt about what should be documented or how records need to be
kept, practitioners should ask themselves:
“Will this action serve the best interests of my patient?
“ Does this action helps in my patient’s safety and the continuity
of his or her dental care?”
 The production, retention, and release of clear and accurate patient
records are an essential part of the dentist’s professional responsibility.
 Success in this task will assist the dentist should a medicolegal claim be
made and can assist the police and coroners in the correct identification
of individuals.