Dental Data Exchange
1.0.0 - STU 1

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## Best Practices

In addition to noting net new dental data concepts within this implementation guide, the work group believe it is beneficial to include best practices for the dental data concepts that are not yet specified. This is to better prepare for dental data exchange concepts that will continue to enhance the current state of data exchange while utilizing the concepts that are already modeled. Best practices noted below include the proper use of the new dental profiles, incorporating multiple dental codes, and attaching additional unstructured information pertinent to the patient’s dental record.

### Populating Bi-directional Medical/Dental and Dental/Dental Exchanges

This IG makes a distinction between medical problems and dental problems.

Dental Providers: In an effort to avoid clutter of the medical problem list, a Dental Condition profile has been defined for all dental-specific diagnoses. Dentists are expected to consider which, if any, dental problems warrant consideration by medical clinicians and therefore should be found on the patient’s medical problem list. Electronic dental record (EDR) system implementers are expected to make this choice apparent to dentists/users through a user interface experience, capture the dentists/users decision for each diagnosis (i.e., medical condition or dental condition), and to map each diagnosis to the appropriate profile:

- Diagnoses that are deemed by dentists to warrant consideration, tracking, and possible treatment by medical professionals should conform to the US-Core Condition profile.
- Diagnoses that would be considered, tracked, and treated only by dentists should conform to the Dental Condition profile.

All conditions or problems associated with both medical and dental conditions should be placed in the Dental Condition profile found under the Dental Fining section of a Dental Consult Note or Dental Referral Note.

Similarly, dental-specific measurements should be shared via the Dental Finding profile and found under the Dental Finding sections of a Dental Referral Note or Dental Consult Note. All non-dental-specific findings, measurements, and observations should conform to the appropriate profile, such as US Core Vitals Observation profile, or PastOrPresentJob Observation profile. If there is no appropriate Observation profile for the nature of the observation, then the base FHIR R4 Observation resource should be used.

- Medical to Dental Referral Note: When a medical provider is referring a patient to a primary dentist for follow up or an initial exam, including oral exam findings in an assessment along with any plans for treatment (e.g., fluoride drops, antibiotic treatments for oral infections) and education provided (e.g., regular flossing) information around patient’s oral health. Also, in the referral, include information on current problems, allergies, recent surgical procedures, implantable devices that would impact the patient’s care.

- Dental to Dental Referral Note: In the case of a referral between a primary dentist and a specialty dentist, include the Dental Findings profile and any procedures completed along with any treatment plans.

- Dental to Medical Consult Note: In sending dental information back to the medical provider in a consult, include any additional medications provided to the patient, diagnoses made, procedures completed, and treatment and follow up plan you created with the patient.

- Dental to Dental Consult Note: In sending dental information back to primary dentist include details on the exam conducted, findings and any treatment or therapies performed. Include any additional medications provided to the patient, diagnoses made, procedures completed, and treatment and follow up plan you created with the patient.

### Use of the Dental Finding, Dental Condition, and US Core Condition Profiles

Implementors should use the following profiles within a Dental Referral Note or Dental Consult Note:

- Dental Condition: This profile contains clinically significant observation confirmed or discovered during a dental visit. It should be used to specify:
  - A dental condition that does not require action, such as a missing tooth (see Scenario 3)
  - A problem that is actionable or may require attention (such as active caries), which may include a reference to evidence of that problem via a Dental Finding.
- Dental Finding: This profile should be used to record oral measurements or assessment scores including an odontogram or periodontal assessment.

The HL7 community recommends the following practices:

- Dental observations that are important to other medical providers (e.g., bleeding gums) should be placed in the US Core Condition profile. (See Scenario 1.)
- Dental diagnoses and observations that a medical provider would likely consider clutter (e.g., caries on left lower second molar – tooth #18) should be placed in the Dental Condition profile and the Dental Findings profiles, respectively. Both of these profiles should be found in the Dental Finding section within a Dental Referral Note or Dental Consult Note. (See Scenario 2.)
- Dental measurements that a medical provider would likely consider clutter (e.g., One cm swelling present on buccal free-gingiva around #29 and #30 with sinus tract present #30B) should be placed in the Dental Finding profile, using the Dental Findings profile on Observation. (See Scenario 3.)

It is recommended to consider appropriate use of a standard concept to represent the Reason for Referral in conjunction with one or more Dental Finding (Observation) resources. The table below is a sample of matched SNODENT and SNOMED codes that describe reasons for referral.

Reason for Referral | SNODENT ID | SNOMED ID | Description
--- | --- | --- | ---
Abscess | 123286D | 128477000 | Abscess
Accretions on teeth (deposits) | 127701D | 6288001 | Accretions on teeth
Bleeding gums | 142683D | 86276007 | Bleeding gums
Dental clearance prior to transplant, surgery, or other treatment cancer | 146328D | 110475006 | Compliance with suggested dental care
Dental decay (dental caries disease) | 118065D | 80967001 | Dental caries
Diabetes | 133643D | 73211009 | Diabetes mellitus
Disturbances in tooth eruption | 144684D | 234972003 | Disturbance of tooth eruption or exfoliation
Dry mouth | 138508D | 87715008 | Xerostomia
Erosion of teeth due to persistent vomiting | 104212D | 52031007 | Erosion of teeth due to persistent vomiting
Evaluate a swelling or other lesion, including infection and rule out oral cancer | 128015D | 65124004 | Swelling
Infection | 138169D | 40733004 | Disorder due to infection
Lack of oral hygiene, including build-up of deposits on teeth | 140234D | 110299009 | Poor oral hygiene
Lack of recent dental care | 212130D | 413313008 | Did not attend dentist in last 12 - 18 months (finding)
Malocclusion | 150365D | 47944004 | Malocclusion of teeth
Oral lesion | 180678D | 1071000119107 | Oral lesion
Patient referral for dental care | 212150D | 103697008 | Patient referral for dental care
Pregnancy | 174950D | 77386006 | Pregnant
Sore gums | 104458D | 11114002 | Sore gums
Swollen gums | 148393D | 309685001 | Swollen gums
TMD pain | 167337D | 298376001 | Temporomandibular joint painful on movement
Tooth abnormalities, such as excessive erosion (eating disorder) or excessive wear of teeth | 135988D | 82212003 | Erosion of teeth
Tooth pain | 131687D | 27355003 | Toothache
Trauma | 128117D | 397869004 | Dental trauma

### Prior Work

Implementers should distinguish prior work from current procedures in the following manner. Procedures performed during previous encounters should be documented as a US Core Procedure with a status of ‘completed’. US Core Procedure requires a procedure code; for historical procedures that were performed elsewhere, and the precise procedure code performed in unknown by an implementing system, users are encouraged to enter an appropriate general dental procedure code.

### Incorporating SNODENT Concepts

Given that most electronic dental record (EDR) systems already support SNODENT, but most electronic health record (EHR) systems only support SNOMED-CT and ICD-10, the recommended practice is to convey both versions of a concept when possible. Whenever possible, the SNOMED-CT term should be provided as the primary code, with the equivalent SNODENT term included as a translation. Failure to include a SNOMED-CT or ICD-10 coded value may result in inability for a receiving system to meaningfully interpret the information provided. Systems that cannot implement SNOMED-CT transmission or reception will not be able to translate over to US FHIR Core. In representing problems, this implementation guide recommends the use of SNOMED CT and understands that some EDRs may use ICD-10 if SNOMED CT is not available.

### Planned Procedures and Encounters using CDT and CPT

When populating the Service Request, if appropriate, implementers should use Current Dental Terminology (CDT) terms to describe the planned encounter. The procedure is encouraged to be from LOINC, SNOMED-CT, CPT-4 , or ICD10 PCS, and similarly the encounter is encouraged to be from a value set consisting of SNOMED-CT values. However, in both cases, the conformance statement linking these elements to terminologies only have the strength of SHOULD. When referring to dental encounters or procedures in the Service Request, a CDT term would be more appropriate and should be used. Additionally, if a procedure is planned, implementers should follow the best practice to include a SNODENT concept.

### Dental Images as Results

Dental images such as bitewing x-rays are not expected to be embedded within a Dental Referral composition or Dental Consultation Note composition. The exchange of actual dental images is expected to occur via secure email or some other secure and private exchange pathway in dental referral use cases. If a narrative describing findings from review of an image is available, it can be conveyed in an Observation resource.

### Referral Identifiers in the Consult Note

To facilitate correlation between a Dental Consult Note and the original referral that led to the resulting consultation, a globally unique referral identifier will be a reference to the specific ServiceRequest instance that was sent in the referral note; the ServiceRequest instance will be referenced from the OrderExtension (extension) in the Dental Consult Note.

### Including UDI Details for Devices and Implants

When device or implant information is included in a dental data exchange document, Unique Device Identifier (UDI) information should also be included about that device or implant if possible. See the Insulin pump insertion example.

### Caries Risk Assessment

For most dental practices, dental caries risk assessments are important references for dental providers. They provide additional context for the urgency of a patient’s dental pain/issue. The work group suggests conveying dental caries risk assessments in the US Core Condition Profile or the Dental Condition profile. Below are examples of dental or periodontal risk identification in a dental record:

- Low
- Elevated Risk

For more information on available Risk Assessment modeling, see the American Academy of Pediatrics, FHIR Standards webpage.

### Patient Self-Management Goals

A goal is represented as a MAY in the Dental Referral Note and the Dental Consult Note, providing specific patient goals separate from instruction. Goals may represent what the patient should do in addition to standard instructions given to the patient. The work group suggests conveying dental goals in the US Core Goal Profile. The US Core Goal Profile may be found in the plan of treatment within a Dental Consult and Dental Referral Notes. Below are examples of self-management dental goals:

- See dentist/regular dental visits
- Healthy snacks
- No soda/sugary drinks/energy drinks
- Brush twice daily
- Less/no junk food/candy
- Floss daily
- Use fluoride toothpaste
- Limit caffeine
- Dental treatment for current teeth
- Tobacco cessation
- Quit/decrease alcohol consumption
- Seek drug abuse/use treatment