DENTAL CLINICAL PRACTICE 5B COMMUNITY DENTISTRY RESEARCH PROJECT
Dental Records in UAE: Are we ready for forensic needs
Dental Records in UAE : Are we ready for forensic needs
Dental records became an essential part of any dental practice and have been increasingly necessary for the past century. The American Dental Association (ADA) defines dental patient record as “the official office document that records all diagnostic information, clinical notes, treatment performed and patient-related communications that occur in the dental office, including instructions for home care and consent to treatment”. (1) Since the 21st century, completeness of dental records have become of major concern due to the fact that it serves as a source of information for both the dentist and the patient. Moreover, it plays an important role in providing a good quality patient care; medico-legal issues, forensic needs, and is essential for teaching purpose and research. (2) Furthermore, it serves for the patient own best interest in case he needs to complete his treatment with another practitioner. Also, it determines the quality control by applying the dental audit, which investigates all the parts of dental care starting from the early patient’s information to evaluate the dental practitioner's capability “to diagnose, treat, use resources and practice evidence-based dentistry”. Quality of life will be affected by all these factors as evaluated by the patient and the professional. (3) As students and future dentists, who have been dealing with dental records for the past 2 years, we learnt the importance of an ideal dental record in making our work easier in terms of follow up and patient comfort, as it is said that “dentists and patients forget, but good records remember”. (2) The aim of the article linking the quality of dental records to forensic needs among 100 dentists of different cities in Rajasthan, India, was to assess the dentist's knowledge regarding the importance of dental record maintained, and to comprehend the average quality of dental records kept by them. A cross-sectional survey was used on randomly selected 100 practicing dentists to collect the information via telephone calls. Only 38% of the participants kept the records, while 62% admitted keeping no records at all. They found that 100% of respondents believed that they aren’t legally obliged to keep the records, at the same time they are all aware of its medico-legal importance and relevance. Regarding forensic needs, only 5% were requested to do age estimation of teeth in forensic cases. This concluded that dental practitioners in Rajasthan are not yet ready for forensic and medico-legal uses. (2) Additional studies done in United States, United Kingdom, Australia and Scandinavia also revealed inadequate documentation. (4) 1
Patient’s dental record doesn’t only consist of written notes and charts, but also radiographs, study casts, clinical photographs, and any laboratory and drug prescriptions. This is clearly a lot to maintain, but it is crucial to keep it in a reachable method at all times. Most studies report that the dental record should be written in a certain way. For example: all basic patients’ personal information should be included in the registration form, and should be clearly stated along with the date of entry. Nevertheless, clinical examination should be the base of the information in the dental record. Moreover, the identity of the treatment’s provider should be mentioned distinctly in the record. Only worldwide used abbreviations should be mentioned in the record. (5) Ink or electronic form should be used to record the information. In case any errors happened while writing the progression sheet, a single line should cross the incorrect material. Deliberate obliteration or alterations of the records after the fact should not be made under any circumstances. Patients’ files should be categorized into active and inactive, according to whether they are receiving dental care by the practice for the past year. (3)
A study performed by the Wisconsin Dental Association (WDA), discovered that the deficiency in uniformity and standardization of dental records resulted from the fact that each dentist is using his own record keeping system. (6) This in turn raised the issue of developing standardized criteria for patient record by the WDA, which will facilitate the assessment of the dental care quality. Many other associations were encouraged to establish guidelines for the components required in the dental record. Some to be mentioned are: the ones developed by ADA in 1987(7), guidelines by the Faculty of General Dental Practitioners in UK (8) And recordkeeping standards developed by the Minnesota State Board of Dentistry in 1997. (9) Moreover, poor record maintenance was noticed in the last two decades in many studies. (10-12,13,14) In one of the studies done in University of Pittsburgh’s School of Dental Medicine, they discussed the essential information that should be included in every patient file by evaluating a 2 years active record for 10 patients with at least 3 treatment procedures. They divided the information needed into 4 categories: obtained clinical data, determine health status, determine plan, and deliver care. For example, the obtained clinical data contains: patient chief complain, medication history, medical history, dental-social history, hard tissue and periodontal chart, intra-oral soft tissue examination, extra-oral head and neck examination, temporo-mandibular joint/occlusion, radiographic history and findings, physician information, alert/summary box, 2
medical history update, and consultation. They concluded that inadequate completeness of dental record would compromise the dentist decision-making and patient care delivering, since each piece of information help in building the architecture of a comprehensive dental record. (4) Meanwhile, there is an increase interest and fast development in forensic odontology due to the rise in mass disasters’ numbers as a result of civil war, massacre and terrorist actions that can end up with disfigurement of human bodies. Moreover, the deceased’s families deserve to get a closure through forensic identification that will help them to deal with their loss. Nevertheless, it plays an important role in building a strong case in situations where there is no enough evidence to apprehend the criminals. (3) As dentists we have tremendous responsibility in keeping complete dental records, since they play a major role in forensic investigations either by comparison or exclusion. In certain situations, we would compare bite marks from an attack or remaining teeth from a decomposed corps with the dental records we have. Forensic odontology “is the application of the art and science of dentistry to resolve matters pertaining to the law”. It varies from evaluation of a bite mark to mass disaster identification of decomposed unidentified bodies. (5) In the year 49 A.D, the first case reported the use of forensic odontology to identify Lollia Paulina. Later, in India another case was reported in 1193 identifying Raja Rathore by his false anterior teeth. (15) In the plane crash that happened in 1988, which resulted in the death of General Zia-Ul-Hag, who was the late president of Pakistan, they used his dentition for identification. Another case was that of Rajiv Gandhi, the late Indian Prime Minister who died in the terrorist attack in 1991. (16) In a questionnaire-based study done in Islam-Abad, they wanted to assist the dentists’ awareness about forensic odontology among dental colleges’ teaching hospitals. They also wanted to evaluate the necessity of adding it to the curriculum of BDS as a subject by its own. The results of 318 questionnaires showed that 93% responded with 100% participants never studied or got any official training in forensic odontology. Furthermore, 60% pointed out that they would probably study forensic as a major subject if the chances were offered in Pakistan. (17) Another cross-sectional study done in Chennai about the awareness of dental practitioners about forensic sciences; revealed that 21% of the respondent's dental professionals did not keep the records in their clinic, and not more that 12% of them are preserving complete record. 3
Additionally, 41% didn’t know how to do the dental age estimation, while when it comes to the correct method of individual identification, 38% failed to describe it. Approximately 18% were unaware of the importance of bite mark patterns. Furthermore, 30% of the participants were uninformed that they can be called for testimony as experts in the court of law in cases of forensic odontology. They discovered insufficient knowledge and lack of experience in the field of forensic dentistry within dentists in Chennai. (18) In the Dental Clinic Guidelines by Dubai Health Authorities (DHA), they emphasize on the maintenance, completeness, accuracy of each patient dental record, and the availability of it whenever requested by another authorized healthcare professionals. As previously mentioned, dental records should include all information relevant to the patient dental needs with special attention given to allergies and troublesome drug reactions. “Furthermore, specific policies should be established to address retention of active records, retirement of inactive records, timely entry of data in records, and release of information contained in records”. Additionally, they suggest that there should be indicators to evaluate the dental clinical performance by the Health Regulation Department. Also, all data submitted by the dental clinics should be up to date with the e-Health guidelines fixed by the DHA. (19) And, according to the Health Record Guidelines set by the Health Regulation Department (HRD) they state that all records (whether medical or dental) is to be retained for at least 10 years for after the last patient visit to any health provider. While files of deceased patients, are required to be kept for 5 years. Nevertheless, files used in medico-legal cases should be stored for up to 20 years as well as files of patients with diseases that could be beneficial for academic and research purposes. (20) In order for dentists to provide the best possible treatment, they need to keep a standard quality of the patient filing system and understand its importance in improving the patient quality of life and their own by protecting them against legal issues. Thus, the assessment of the records should be evaluated and checked periodically to ensure that it has met the standards provided by the health authority. Several studies have therefore made it their goal to evaluate the health providers and professionals’ awareness on that matter. In our study, our aim is to investigate the quality and completeness of dental records among dental practices in the private sector in the UAE, measure the dentist’s awareness, and evaluate if it meets up the forensic odontology demands. 4
Materials and Methods: A cross sectional study will be carried out in a form of a survey, to evaluate the completeness and quality of dental records in UAE and to measure the dentists’ awareness about their importance. The estimated sample size will consist of a total of 200 dental practitioners selected randomly from a list containing the names of all practicing dentists in UAE, with expectancy of compliance of n=100 minimum of dentists.(1) The sample will be selected by a computer-based manner. The participants must meet the following inclusion criteria: dental practitioners in the private sector of UAE (Abu Dhabi, Dubai, Sharjah), who have agreed to participate in the study after signing a consent form. There was no difference between general practitioner and specialist nor the years of experience in selecting the sample. Those who will refuse to participate will be excluded from the study and their percentage will be calculated in the results. We will manually distribute a consent form along with the questionnaire to the participating dentists in their dental clinic between November 2014_ January 2015. The consent form will explain the objective, identity of the researchers, and confirmation of the study confidentiality, inclusion and exclusion criteria and whom to contact in case they have any inquires or complains. Those who agree to be in the study must sign the consent form and answer the attached questionnaire. Each questionnaire is number coded for the purpose of identification and collection. The questionnaire will start with a small sector that the participant must fill out regarding his/her personal information, which includes age, gender, years of experience, and type of license the dentist’ have. The last two will be our variables as they may play a role in degree of completeness and awareness. Following this section, the participant must answer a set of 27 close-ended questions. Twenty-two of the questions which are designed to check the components of the dental records and the quality of these records, will be on a scale base with: for all patients=5, for most of the patients=4, for some patients=3, for few patients= 2, Not at all= 1.However, questions about the form in which the records maintained, the typing martial, and the use of abbreviations were obtained in multiple choice questions form. These questions were designed based on the criteria of a complete dental record obtained from the 2 articles (Dental records: an overview) and (What's the deal with dental records for practicing dentists? Importance in general and forensic dentistry). (2)(3) The last two questions are related to dentist’s attitude toward forensic odontology based on a study that was conducted by Baig et al, Pakistan 5
Oral & Dental Journal, 2014. (4) A pilot study will be conducted to evaluate the applicability of the questionnaire. After answering the questionnaire, we will gather them for data collection. The data will be calculated in the form of percentages using Microsoft excel program for more accuracy. According to the results the quality of dental records will be classified into 3 categories (complete, partially complete, incomplete).The complete category will be defined as most of the answers chosen in the questionnaire were (scale 5 or 4), partially complete were (scale 3) and incomplete were (scale 1 or 2) .The results processed will be illustrated by means of frequency tables. The frequency tables will then be schematized with a simple bar graph or pie graph. Finally, we will use the results obtained to write a discussion and draw a conclusion.
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Results: In this cross-sectional study, the initial sample consisted of 150 dental practitioners in the private sector in Dubai,Sharjah and Abu Dhabi in UAE. Out of the total sample 50 dentists refused to participate due to busy schedule and confidentiality reasons although we assured them that their personal information won’t be reveled. The following section illustrates the most important findings of the study: Regarding the characteristic of the sample of the study (table 1) Age: 38 years old Gender: 61% of the participants were male (n=61), while the other 39% were female (n=39). Years of Experience: 67% of the participate had more than 10 year of experience Specialty: Out of the 100 samples, 60% of them were general practitioners and 40% were specialists. The majority of the participants indicated that they keep the record of their patients for 5 years (88%). On the other hand, 92% asked about relevant medical history of their patient and the reason for the visit. Considering the proposed treatment plan for each patient, 81% performed it. 66% have separated dental chart, 60% have separated periodontal chart, 63% recorded the denture details, and 69% don’t usually ask about the previous dentist name, 72% keep referrals and consultations letter, 75% keep prescription medication papers. Most of the dentists (82%) asked their patient for consent form, 79% of dentists keep the patient’s x-rays, photographs and models for 5 years, and 85% mentions the detailed treatment by date, 71% update health history regularly, 76% can easily access and search patient’s record once needed. (Table 2)
However, 33% of the contributors stated that they don’t perform intra-oral examination for most of their patients, while 44% don’t conduct an extra-oral examination, 51% indicated that they don’t correct mistakes in the record with a single line (Table 2).
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Most of the records (42%) were in both forms: digital and paper (Figure-1). 75% indicated that they use ink in writing their records (Figure-2). When it comes to the use of abbreviations, 80% use abbreviations sometimes. (Figure-3)
No significant difference was observed between general practitioners and specialists, and between male and female in regards of the components of the records surveyed (Table3, table 4). However more years of experience was associated with denture details recordings and correcting the mistakes in the record with single line (chi square. P<0.05)(Table 5).
Discussion: The quality of dental records and dentistsâ&#x20AC;&#x2122; awareness about their importance has been the subject of much research around the world, but none of which has been conducted in the UAE. With the comprehensive guidelines set by the ministry of health in UAE regarding dental records, we expected the majority of the participants to have the components of the records completed and recorded for most of their patients. Thus, the completeness and the quality of the records in UAE with variables such as age, gender, years of experience, and type of licenses were investigated in our study. According to the 2 articles from which we obtained the criteria of a complete dental record (dental records: an overview) and (what is the deal of dental records for practicing dentists? Importance in general and forensic dentistry) all the basic patientsâ&#x20AC;&#x2122; personal information should be included in the registration form, which was recorded in our study to be as follows: Marital status (80%), Patient contact number (99%), Postal address (65%), Patient occupation (76%). Nevertheless, clinical examination should be the base of information in the record. While in our study, 33% and 44% stated that they donâ&#x20AC;&#x2122;t perform intra-oral examination, and extra-oral examination, respectively. This could be explained based on the study done by (Astekar M et al, 2011) because some dentists believe that they are not legally obliged to keep the records (100%), and are not aware of its medico-legal importance and its relevance. 8
Several studies have found low quality records recording among dental practitioners. For instance, the study conducted in Rajasthan, India (Astekar M et al, 2011) showed that only 38% of the participants kept the records, while 62% admitted keeping no records at all. Whereas in our study, the majority of the participants (88%) keep their patientsâ&#x20AC;&#x2122; record for 5 years and 92% asked about relevant medical history of their patient and the reason for their visit, indicating a high efficiency in the record keeping system in the UAE compared to that found in India. This can be explained due to the more restricted regulations on the dentistsâ&#x20AC;&#x2122; medical responsibility in the UAE. For example, a study conducted in the state of Wisconsin by (Helminen SE et al, 1998) revealed that only 26% of the medical health record was up to date and 93% recorded the periodontal index of treatment, while 16% having the dental status. (6) On the contrary, we found that 71% of the records were up to date regarding medical health, 66%,60%, recording of dental and periodontal charting, respectively. Which indicate that the previously mentioned result does not meet the expected standard of record keeping system. Moreover, Helminen SE et al, found that female dentists and dentists younger than 37 years tended to record more information, which could be related to the females and younger dentists being more likely to pay attention to details and because the dental education system started to emphasize more in the importance of a completed record. While in our study, no significant difference was recorded between male and female, and between general practitioners and specialists, in regards to the components of records maintained. On the other hand, more years of experience were associated with denture details recording and correcting the mistakes in the record with single line (p <0.05).
According to Acharya A et al, at the University of Pittsburgh, they acquired several date from: patient chief complain, medication history, medical history, to intra oral soft tissue examination and radiographs, and they saw that lack of completeness of dental records would jeopardize dentist decision-making and patient care delivering. (5) In the contrary, we found that most of the dentists (82%) asked for consent form from their patients, which is an important part 9
of any record that can save the dentist from a lot of medico-legal issues. While, regarding x-rays and photographs, 79% of the dentists stated that the keep them in the patientâ&#x20AC;&#x2122;s record. This can be related to the Dental Clinic Guidelines written by Dubai Health Authorities, which is emphasizing on the completeness and accuracy of patient dental record. (19) Health Regulation Department (HDR) also compel that all records (whether medical or dental) is to be retained for at least 10 years after the patientsâ&#x20AC;&#x2122; last visit. While files of deceased patients, are required to be kept for 5 years, which was the case in our study. (20)
In our study, 42% of the records were in both forms: digital and paper and 75% were written in ink. This should be enhanced to more digital records and no more use of pencil in writing records since this lower the quality of the record by being able to manipulate the information on it.
Conclusion: Dentists all over the world have a direct effect in their patientsâ&#x20AC;&#x2122; quality of life and are responsible of providing the best care possible for their patients. Moreover, dental practitioners in the United Arab Emirates are becoming more involved in the medico-legal and forensic odontology issues. So, in order to protect them selves against these litigations, a high quality record should be kept in a standard filing system. Due to the lack of awareness of the importance of dental records noticed in different studies done worldwide, both dentists and patients will be at a higher risk of legal and health hazards. However, most of the components of the record were found to meet the standards set by the Health Regulation Department (HRD) in UAE. On the other hand, the percentage of dentists obtaining consent form (82%) is considered inadequate since it should be 100% for all patients in all different procedure including a check ups. There was no gender or specialty difference noticed in the sample surveyed, but the statistically significant difference found in more experienced dentist regarding denture details could be because they are more enrolled in prosthetic work than dentists with less experience.
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As the complete record will serve the patient’s own best interest and will protect the dentists against any malpractice claims, It’s necessary to improve the quality of the records by having a more periodic check up for all the clinics in UAE by the health authorities. And that’s why it is of great importance to promote and measure the dentists’ awareness and gives them the proper training programs about how to meet the forensic odontology demands by obtaining a high quality record for their patients.
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