Differences in dental notation can lead to unexpected errors. How well do you know your notes?
As dental professionals, we must be able to clearly and reliably identify individual teeth. Problems can arise with illegible hand-written records, typographical errors and issues with right/left laterality and upper/lower descriptions1.
These problems are compounded when a second professional colleague needs to interpret our notation, and such problems can lead to risks to patient safety. For example, if a tooth is erroneously removed as part of an orthodontic plan or endodontic treatment is undertaken on the wrong tooth, the patient is harmed and the dental professional is at risk of a complaint and a claim.
Starting with the Viennese dentist Dr Zsigmondy in 1861, and soon followed by Dr Palmer in the USA (leading to the popular Zsigmondy/Palmer system2), a number of different dental notation systems have been developed.
To summarise these, the various notations used to identify the upper left first molar tooth are as follows:
||Upper left first molar tooth
These notation systems have various advantages and disadvantages, based on time efficiency, simplicity of use, reliance on legible handwriting, susceptibility to typographical errors and confusion between other notation systems.
In recent years, dentistry has moved increasingly towards a digital workflow, with clinical records and professional communication evolving from paper based, hand-written notes and letters to computer based methods. As a result, the different dental notation systems have become either more or less suitable for routine use.
While all systems are likely to be taught on undergraduate programmes, individual systems are favoured in different clinical settings and countries across the world. With national and international communication as well as travel for patients and dental professionals now being commonplace, it is more important than ever to use dental notation systems that are unambiguous to reduce the risk of miscommunication that can lead to patient harm.
With consideration of all these factors, the following are recommended as minimum required notation methods:
Electronic clinical records:
Hand written clinical records
Clinical letters to professional colleagues, such as referral to a specialist
Communicating with other dentists regarding teeth to be extracted3:
Two different methods, one of which must be long-hand: 'upper right first molar tooth. UR6 - gold crown'. Note that a description of the tooth that is to be extracted can be helpful.
Whiteboards for dental extractions:
Palmer: this is the recognised dental notation identified in the NatSIPPS documentation (NHS England)4 as the notation to be used on whiteboards for dental extraction, as it is very well recognised and visually simple to understand.
Long hand: 'Your upper right first molar tooth', to aid patient understanding.
In addition, for specific situations:
- Deciduous teeth must be identified by capital letters, with lower case letters avoided (for example, ULB not ULb).
- Supernumerary teeth should be described in words, irrespective of whichever dental notation has been used as well.
- Where there are two erupted permanent molar teeth, the use of the terms 'first standing molar' and 'last standing molar' should be used in addition to any dental notation to aid clarity.
- Where there are three incisors, the descriptions 'middle of three', 'left of three' and 'right of three lower incisors' will aid clarity.
It is increasingly important to use clear and unambiguous dental notation systems. Which system to use will differ depending on the situation in which they are required.
By following these recommendations we will be able to reduce the chance of a mistake occurring, along with the associated risk of harm to our patients and damage to our professional reputation.
Martin Ashley is a consultant and honorary senior lecturer in restorative dentistry at the University Dental Hospital of Manchester. He and his colleagues have a strong interest in patient safety within dentistry and have lectured and published widely on related subjects such as dental notation and correct site surgery.
See more by Martin Ashley