Dental Data Exchange
1.0.0 - STU 1

Publication Build: This will be filled in by the publication tooling

## Background

Currently, there is no standard for the exchange of discrete dental observations between dental providers. While some dental electronic health record (EHR) systems have implemented C-CDA for data exchange, that standard was primarily built for medical care and does not include most structured data elements needed by dental providers.

The Department of Defense (DoD) and the American Dental Association (ADA) recognized the need for foundational dental data exchange between medical and dental practices and among dental practices. The DoD wishes to support the dental health of service members and their readiness for deployment. The ADA wishes to support a continued, industry-wide, drive to promote and enhance standardized and structured dental data for seamless interoperability using CDA and FHIR. Lantana Consulting Group and the CareQuest Institute for Oral Health have collaborated to develop this FHIR Dental Data Exchange Implementation Guide in parallel to the CDA Dental Data Exchange Implementation Guide.

Representatives from the DoD, ADA, and industry leaders convened the Dental Data Exchange Project in late Summer 2019. The first project milestone was identifying key data concepts that could successfully transmit a dental referral between two dental systems, or between a medical and a dental system. The project focused on adding structure to unstructured dental data elements while maintaining alignment with FHIR US Core Implementation Guide, HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 2 - US Realm, and HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm.

Independently, the CareQuest Institute for Oral Health identified a need for communication and coordination of care between oral health providers and other health care disciplines. The inability of health information systems to meaningfully share data limits the healthcare system’s ability to address whole-person care across the lifespan, and therefore is detrimental to health outcomes. The electronic communication of clinically relevant medical or dental information when referring a patient to a dental provider, and the ability to close the referral loop, via a dental consultation note to the referring healthcare providers is vital to improving care coordination and provider collaboration. The CareQuest Institute for Oral Health joined this project in Fall 2019, bringing their requirements to the development of standard dental referral and dental consultation notes.

### Current Project

This project defines FHIR artifacts to extend the C-CDA on FHIR Referral Note and Consultation Note to include dental specific data concepts called for in the ANS/ADA 1084 standard and the CareQuest Institute’s MORE Care and Oral Health Value-Based Care initiatives.

The project references value sets set by the Systematized Nomenclature of Dentistry (SNODENT) working group, under SNOMED-CT. SNODENT is an official subset of SNOMED-CT that provides standardized terms for describing dental disease, captures clinical detail and patient characteristics, supports analysis of patient care services and outcomes, and is interoperable with electronic health record (EHR) and electronic dental record (EDR) systems. Additionally, SNODENT is mapped to ICD-10-CM for reporting diagnoses for billing. SNODENT includes a web-based search browser (ADA Browser®, where implementors can browse dental related terms and code sets.

The project uses the ADA 1084 as the authoritative reference for dental data inclusion because the ADA created it through consensus across dental providers about what shared dental concepts could be exchanged. The work group compared the ADA 1084 to the FHIR R4 standard, identifying gaps in FHIR representation of dental data concepts. The project prioritized ADA 1084 dental data elements within data domain categories and grouped the data domains by Dental Referral Note (referral sent to another system, requesting dental services) and Dental Consult Note (referral outcome sent back to requester).

### Dental Use Case Scenarios

Use cases can bridge understanding between conceptual interpretations and technical implementation of this guide. Four use cases were tested at the May 2020 FHIR Connectathon: Dental Summary Exchange Track, and further refined by the project.

The use cases outlined in this IG show the complexity of the information that can be exchanged between a dental and medical system or two dental systems. Fully-formed XML sample files representing the data included in each of these scenarios are published with this implementation guide. Additional use cases are available on the CareQuest Institute website.

The figure below represents the high-level workflow described across Scenarios 1 (Medical to Dental Referral Note) and 2 (Dental to Medical Consultation Note).

### Scenario 1: Medical to Dental Referral Note

Patient A is a 30-year-old male who has mild hypertension, Type 1 Diabetes, and has an insulin pump. He sees his primary care physician, Dr. John M at Good Health Clinic, for a routine, annual check-up. Aside from medical concerns, Patient A mentions increasing pain in his left lower jaw and some occasional bleeding from his gums. Dr. John M makes an urgent referral to a dentist for further evaluation and discusses the plan with Patient A, who agrees with the plan. Dr. John M generates a Patient Referral Note that includes data describing the dental related findings. Before Patient A leaves, the referral coordinator at the front desk schedules an appointment for him to see Dr. Drew Dentist for the next day.

Capability Statement references: Medical office system is the Document Source (i.e., server) that generates the Dental Referral Note and the Dental office application is the Document Consumer (i.e., client) that consumes the Dental Referral Note.

Patient has pain in his lower left jaw and occasional bleeding from his gums - referring for dental evaluation.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 1: Medical to Dental Referral Note.

FHIR Profile | FHIR Data Element | CDA Section | CDA Entry | Data Values
--- | --- | --- | --- | ---
Dental-Specific Profiles |  |  |  |
Dental Communication | Communication.payload.content | Instructions Section (V2) | N/A | Pt. Education: Advised to see dentist regularly, brush 2x/day w/ fluoride toothpaste, floss
Dental Service Request | ServiceRequest.code ServiceRequest.reasonCode | Plan of Treatment Section (V2) | Planned Encounter (V2) | Dental Referral: Feb 15, 2020 at 3 pm; priority – ASAP 103697008 Patient referral for dental care (procedure) SNOMED CT 27355003 Pain in tooth SNOMED CT 301716002 Left lower quadrant pain SNOMED CT 86276007 Bleeding gums SNOMED CT
US Core Profiles |  |  |  |
US Core AllergyIntollerance | AllergyIntollerance.code | Allergies and Intolerances Section (entries required) (V3) | Allergy Concern Act (V3) / Allergy - Intolerance Observation (V2) | 7980 Penicillin G (Ingredient) RxNorm
US Core Condition | Condition.category Condition.code | Problem Section (entries required) (V3) | Problem Concern Act (V3) / Problem Observation (V3) | Value: 38341003 Hypertensive disorder (disorder) SNOMED CT Translation: 175027D Hypertensive disorder (disorder) SNODENT Value: 46635009 Type1 diabetes SNOMED CT Translation: 175321D Type 1 diabetes SNODENT Value: 309685001 Swollen gums SNOMED CT Translation: 148393D Swollen gums SNODENT Value: 276453000 Teeth covered in plaque (finding) SNOMED CT Translation: 108723DTeeth covered in plaque (finding) SNODENT Value: 27355003 Toothache (finding) SNOMED CT Translation: 108723D Toothache (finding) SNODENT Value: 86276007 Bleeding Gums SNOMED CT Translation: 142683D Bleeding Gums SNODENT Value: 609402003 At high risk for dental caries (finding) SNOMED CT Translation: 179051D At high risk for dental caries (finding) SNODENT
US Core Encounter | Encounter.status Encounter.class Encounter.type Encounter.period Encounter.priority | Encounters Section | componentOf / encompassingEncounter | Office visit: Feb 14,2020 at 3:00 pm 99201 Level 1 New Patient Office Visit CPT
US Core Immunization | Immunization.vaccineCode Immunization.occurenceDateTime | Immunization Section (entries required) (V3) | Immunization Activity (V3) / Immunization Medication Information (V2) | 08 Hepatitis B vaccine CVX Administered on 1/4/2020
US Core Medication | Medication.code | Medications Section (entries required) (V2) | Medication Activity (V2) / Medication Information (V2) | 314076 Lisinopril 10mg Oral Tablet RxNorm
US Core MedicationRequest | MedicationRequest.status Medicationstatus.intent MedicationRequest.authoredOn MedicationRequest .dosageInstruction.route MedicationRequest .dosageInstruction .doseAndRate | Medications Section (entries required) (V2) | Medication Activity (V2) / Medication Information (V2) | Lisinopril 10 mg tab, taking 1 tab once a day
US Core Patient | Patient.name Patient MRN (identifier) Patient.address Patient.telecom Patient.birthDate Patient.gender Patient.us-core-ethnicity (extension) Patient.us-core-race (extension) | US Realm Header | recordTarget / patientRole | Patient A MRN: 5152020 123 Test. Dr. Denver CO 80204 phone: (123)456-7890 email: testA@email.com 01-01-1990 Male Not Hispanic or Latino White
US Core Procedure profile | Procedure.code | Medical Equipment Section | Procedure Activity Procedure (V2) / Product Instance | Insertion of insulin pump on November 3, 2013
US Core Organization (Referring Organization) | Organization.identifier:NPI Organization.active Organization.name | US Realm Header | custodian / assignedCustodian / representedCustodianOrganization | NPI 1316452725 Good Health Clinic
US Core Practitioner (Referring Practitioner) | Practitioner.identifier:NPI Practitioner.name Practitioner Organization | US Realm Header | author / assignedAuthor | NPI: 1234567411 Dr. John M Good Health Clinic
US Core PractitionerRole (Referring PractitionerRole) | PractitionerRole.organization PractitionerRole.code | US Realm Header | author / assignedAuthor / code | 207QA0505X Family Medicine [Adult Medicine] Healthcare Provider Taxonomy (HIPAA)
US Core Vital Signs (Observation) | Observation.component.value | Vital Signs Section (entries required) (V3) | Vital Signs Organizer (V3) / Vital Sign Observation (V2) | Temp: 98.5 Pulse: 78 Respiration: 20 BP: 120/80
C-CDA on FHIR Based Profiles (Referral Note) |  |  |  |
Dental Referral Note | Composition.section.code = ‘48765-2’ | Allergies and Adverse Reactions Section | Allergy Concern Act (V3) / Allergy - Intolerance Observation (V2) | 7980 Penicillin G (Ingredient) RxNorm
Dental Referral Note | Composition.section.code = ‘51848-0’ | Assessment Section | N/A | Patient has pain in his lower left jaw and occasional bleeding from his gums. Referring for dental evaluation.
Dental Referral Note | Composition.section.code= ‘10164-2’ | History of Present Illness Section | N/A | Patient has not visited a dentist or received fluoride treatments in the past four years while away at college.
Dental Referral Note | Composition.section.code= ‘61146-7’ | Goal Section | Goal Observation | No soda / sugary drinks / energy drinks. Use fluoride toothpaste
Dental Referral Note | Composition.section.code= ‘75310-3’ | Health Concern Section (V2) | Health Concern Act (V2) / Problem Observation (V3) | 230572002 Neuropathy due to diabetes mellitus SNOMED CT
Dental Referral Note | Composition.section.code= ‘11369-6’ | Immunization Section (entries required) (V3) | Immunization Activity (V3) / Immunization Medication Information (V2) | 08 Hepatitis B vaccine CVX Administered on 1/4/2020
Dental Referral Note | Composition.section.code= ‘69730-0’ | Instructions Section | Instructions Section | Pt. Education: Advised to see dentist regularly, brush 2x/day w/ fluoride toothpaste, floss
Dental Referral Note | Composition.section.code= ‘46264-8’ | Medical Equipment Section (V2) | Procedure Activity Procedure (V2) / Product Instance | 443263006 Insertion of insulin pump (procedure) SNOMED CT 69805005 Insulin pump SNOMED CT 212124D Insulin pump SNODENT UDI Details: • UDI: Unknown • Company Name: MDiabetic • Brand Name: INDEPENDENCE® Insulin Pump • Model Number: 100-INP
Dental Referral Note | Composition.section.code= ‘10160-0’ | Medications Section | Medication Activity (V2) / Medication Information (V2) | 314076 Lisinopril 10mg Oral Tablet RxNorm, taking 1 tab once a day
Dental Referral Note | Composition.section.code= ‘18776-5’ | Plan of Treatment Section | Planned Encounter (V2) | D0150 Comprehensive Oral Evaluation CDT
Dental Referral Note | Composition.section.code= ‘29762-2’ | Social History Section (V3) | Smoking Status – Meaningful Use (V2) and Social History Observation (V3) | 266919005 Never smoked tobacco (finding) SNOMED CT 224302000 Received higher education college education (finding) SNOMED CT 106302007 Accountant (occupation) SNOMED CT
Dental Referral Note | Composition.section.code= ‘42349-1’ | Reason for Referral Section (V3) | Patient Referral Act/ Indication (V2) | Dental Referral: Feb15, 2020 at 3 pm; priority – ASAP 103697008 Patient referral for dental care (procedure) SNOMED CT 27355003 Pain in tooth SNOMED CT 301716002 Left lower quadrant pain SNOMED CT 86276007 Bleeding gums SNOMED CT
Da Vinci Profiles |  |  |  |
HRex Coverage | Coverage.status Coverage.payor | Payers Section (V3) | N/A | Aetna Comprehensive Medical / Dental Insurance
Occupational Data for Health (ODH) Profiles |  |  |  |
Past Or Present Job | Observation.value[x] | Social History Section | Social History Section | Accountant or Auditor

### Scenario 2: Dental to Medical Consult Note

Patient A sees Dr. Drew Dentist on February 16th for an urgent evaluation based on a referral from Dr. John M, his primary care provider. Patient A is a new patient at Dr. Dentist’s office, so a new patient record is created. Dr. Dentist reviews the risk assessment, the Dental Referral Note from Dr. John M, and the rest of the information that was pre-populated in the dental EHR. Dr. Dentist performs an oral evaluation and two PA radiographs. He identifies two areas of concern: patient has a significant, non-restorable caries lesion (decay) on the left lower back molar (tooth #18) with signs of infection, and early signs of decay on the right upper incisor (tooth #7).

Dr. Dentist recommends an extraction of the left lower molar (tooth #18) and restoration of the right upper lateral incisor (tooth #7) due to a caries lesion (decay). Dr. Dentist explains the importance of using a fluoride toothpaste when brushing twice daily with daily flossing, and of the need for bi-annual dental visits for examination and prophylaxis (cleaning).

Before Patient A leaves, the receptionist schedules an appointment for the extraction of tooth #18 on February 23rd, another appointment for restoration of tooth #7 on March 3rd, and a follow-up appointment for a complete examination, including radiographs and prophylaxis on March 10th.

Dr. Dentist reviews Patient A’s current medication list, notes an allergy to penicillin that is a counter-indication for his typical recommendation of amoxicillin, prescribes Erythromycin 500 mg every six hours for the infection and recommends alternating over-the-counter Ibuprofen and Acetaminophen for pain. Also, he generates a Dental Consultation Note back to Dr. John M with a summary of Patient A’s visit including the new prescription, planned procedures, future appointment dates, and patient specific dental goals.

Capability Statement references: The Dental office system is the Document Source (server) that generates the Dental Consult Note and the Medical office application is the Document Consumer (i.e., client) that consumes the Dental Consult Note.

Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment. Significant decay on the left lower second molar (tooth #18) with signs of infection. Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7). Recommend an extraction of the left lower second molar (tooth #18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 2: Dental to Medical Consult Note.

FHIR Profile | FHIR Data Element | CDA Section | CDA Entry | Data Values
--- | --- | --- | --- | ---
Dental-Specific Profiles |  |  |  |
Dental Communication | Communication .payload .content | Instructions Section (V2) |  | Patient A educated on the benefits of using a fluoride toothpaste, daily flossing, and bi-annual routine dental cleaning visits.
Dental Service Request | ServiceRequest.code NOTE: ServiceRequest.identifier is recommended to be persisted and used as the unique ServiceRequest linkage between Consult Note and Referral Note. | Plan of Treatment Section (V2) |  | Planned Visits: Visit 1 - Feb 23, 2020 CDT D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Tooth #18 Visit 2- March 3, 2020 CDT D1352 Preventive resin restoration in a moderate to high caries risk patient-permanent tooth. CDT D1110 prophylaxis - adult CDT D0210 Full Mouth Radiographic Survey
Dental Condition | Condition.code Condition.bodySite | Dental Findings Section | Problem Observation (V3) | Value: 80967001 Dental caries (disorder) SNOMED CT Translation: 118065D Dental caries (disorder) SNODENT targetSiteCode: 48402004 Structure of mandibular left second molar tooth SNOMED CT Translation: 161372D Structure of mandibular left second molar tooth SNODENT Value: 427898007 Infection of tooth SNOMED CT Translation: 181608D Infection of tooth SNODENT targetSiteCode: 48402004 Structure of mandibular left second molar tooth SNOMED CT Translation: 161372D Structure of mandibular left second molar tooth SNODENT Value: 80967001 Dental caries SNOMED CT Translation: 118065D Dental caries SNODENT targetSiteCode: 245574002 Entire permanent maxillary right lateral incisor tooth SNOMED CT Translation: 161941D Entire permanent maxillary right lateral incisor tooth SNODENT
Dental Finding | Observation.code Observation.value | Dental Findings Section | Result Organizer (V3) / Result Observation (V3) | Code: 32916-9 Horizontal overlap [Length] Maxilla and Mandible Measured LOINC Value = 3 Units = mm
US Core Profiles |  |  |  |
US Core AllergyIntollerance | AllergyIntollerance.code | Allergies and Intolerances Section (entries required) (V3) | Allergy Concern Act (V3) / Allergy - Intolerance Observation (V2) | 7980 Penicillin G (Ingredient) RxNorm
US Core Organization (Consulting Organization) | Organization.name | US Realm Header | custodian / assignedCustodian / representedCustodianOrganization | Name = Good Oral Health Clinic NPI = 1316452726 Address = 54321 Main Street, Fairfax, VA, 22031
US Core Practitioner (Consulting Practitioner) | Practitioner.identifier:NPI Practitioner.name Practitioner Organization | US Realm Header | author / assignedAuthor | NPI = 1034567384 Name = Dr. Drew Dentist Org = Good Oral Health Clinic
US Core PractitionerRole (Consulting PractitionerRole) | PractitionerRole.code PractitionerRole.specialty | US Realm Header | author / assignedAuthor / code | Healthcare Provider Taxonomy (HIPAA) 122300000X Dental Providers; Dentist Provider Role (HL7) RT - Referred to Provider
US Core Encounter | Encounter.status Encounter.period | US Realm Header | componentOf / encompassingEncounter | Performed Feb 16, 2020 11am EST CDT D0140 limited oral evaluation - new or established patient
US Core MedicationRequest and Medication | Medication.code MedicationRequest.dosageInstruction | Medications Section (entries required) (V2) | Medication Activity (V2) / Medication Information (V2) | 314076 Lisinopril 10 mg Oral Tablet RxNorm 197650 erythromycin 500 MG Oral Tablet RxNorm 310965 ibuprofen 200 MG Oral Tablet RxNorm 313782 acetaminophen 325 MG Oral Tablet RxNorm
US Core Patient | Patient.us-core-ethnicity (extension) Patient.name Patient.gender | US Realm Header | recordTarget / patientRole | Patient A MRN: 2020515 123 Test. Dr. Denver CO 80204 phone: (123)456-7890 email: testA@email.com 01-01-1990 Male Not Hispanic or Latino White
US Core Procedure | Procedure.code | Procedures Section (entries optional) (v2) |  | CDT D1206 topical application of fluoride varnish
US Core Vital Signs Observation | Observation.component.value | Vital Signs Section (entries required) (V3) |  | Temp: 99 deg F Pulse: 82 bpm BP: 120/80
US Core Condition | Condition.code Condition.bodySite | Problem Section (entries required) (V3) | Problem Observation (V3) | Value: 38341003 Hypertensive disorder (disorder) SNOMED CT Translation: 175027D Hypertensive disorder (disorder) SNODENT Value: 46635009 Type 1 diabetes SNOMED CT Translation: 175321D Type 1 diabetes SNODENT
C-CDA on FHIR Based Profiles (Consult Note) |  |  |  |
Dental Consult Note | Composition.section.code=’ 51848-0’ | Assessment Section (V2) | Assessment Section (V2) | Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment. Significant decay on the left lower second molar (tooth #18) with signs of infection. Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7). Recommend an extraction of the left lower second molar (tooth#18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion
Dental Consult Note | Composition.section.code=’ 10164-2’ | History of Present Illness Section | History of Present Illness Section | The patient has not visited a dentist or received fluoride treatments in the past four years while away at college.
Dental Consult Note | Composition.section.code=’ 29299-5’ | Reason for Visit Section | Reason for Visit Section | Patient referred for evaluation and treatment for tooth ache lower left.
Dental Consult Note | Composition.section.code=’ 29762-2’ | Social History Section | Social History Section | Non-smoker, college education and full time job as accountant
Dental Consult Note | Composition.section.code=’ 69730-0’ | Instructions Section |  | Patient educated on the benefits of using a fluoride toothpaste, daily, flossing, and bi-annual routine dental cleaning visits.
Da Vinci Profiles |  |  |  |
H Rex Coverage | Coverage.status Coverage.payor | Payers Section (V3) | Payers Section (V3) | Aetna Comprehensive Medical /Dental Insurance

### Scenario 3: Dental to Dental (Endodontist) Referral

Patient A contacts Dr. Drew Dentist complaining about pain in lower right quadrant of his mouth. He mentioned the pain started two weeks ago and has worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. Patient A is able to eat regular food but is only chewing on the left side. He is taking 400mg ibuprofen every 8 hours for pain.

Patient A has a history of hypertension and takes Lisinopril 10mg tablet once daily. He is also taking erythromycin 500mg every 6 hours for the infection, and additional ibuprofen for pain as needed. He is allergic to penicillin.

Dr. Dentist takes Patient A’s clinical impressions and sends referral to Endodontist for an evaluation of tooth #30 and endodontic therapy #30. Referral included medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations.

Capability Statement references: General Dentist office system is the Document Source (i.e., server) that generates the Dental Referral Note and the Dental specialist office application is the Document Consumer (i.e., client) that consumes the Dental Referral Note.

#30 pulpal necrosis and periapical pathosis with draining fistula. Clinical impression is that possible vital pulp remnants remain. #30 possible cracked DB cusp; rule out cracked tooth. Clinical impression is that tooth is restorable. #29 D caries lesion. On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration;#32 impacted with possible full boney impaction. One cm swelling present on buccal free-gingiva around #29 and #30 with sinus tract present #30B. Periodontal pocket depth WNL.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 3: Dental to Dental (Endodontist) Referral.

FHIR Resource/Profile | FHIR Data Element | CDA Section | CDA Entry | Data Values
--- | --- | --- | --- | ---
Dental-Specific Profiles |  |  |  |
Dental Finding | Observation.code Observation.value | Dental Findings Section | Result Organizer (V3) / Result Observation (V3) | Code: 18782-3 Radiology Study Observation LOINC Value: "Radiographic results showed #32 full bony impaction, #28 endosteal (root form) implant with full crown restoration, and tooth #30 with small PA lesion mesial root. Radiographic caries lesion #29 distal caries lesion (ADA Caries Classification System moderate caries lesion). Other WNL"
Dental Finding | Observation.code Observation.value | Dental Findings Section | Problem Observation (V3) | Tooth 30: targetSiteCode: 28480000 Permanent lower right first molar tooth SNOMED CT Translation: 160770D Permanent lower right first molar tooth SNODENT Code: 109727004 Dental restoration present SNOMED CT Translation: 120871D SNODENT Extra targetSiteCode: 90933009 Structure of distal surface of tooth Extra translation: 146014D Structure of distal surface of tooth Code: 109591005 Tooth tender to percussion SNOMED CT Translation: 128058D Tooth tender to percussion SNODENT Code: 109594002 Tooth sensitivity to cold SNOMED CT Translation: 108969D Tooth sensitivity to cold SNODENT Code: 109596000 Tooth sensitivity to pressure SNOMED CT Translation: 106172D Tooth sensitivity to pressure SNODENT Tooth #28: targetSiteCode: 80140008 Permanent lower right first premolar tooth SNOMED CT Translation: 161496D Permanent lower right first premolar tooth SNODENT Code: 278552004 Dental crown present SNOMED CT Translation: 178492D Dental crown present SNODENT Code: 714543007 Dental bone matrix implant, metallic (physical object) SNOMED CT Translation: 190187D SNODENT Tooth #32: targetSiteCode: 38994002Permanent lower right third molar tooth SNOMED CT Translation: 161121D Permanent lower right third molar tooth SNODENT Code: 109511009 Completely impacted tooth in bone SNOMED CT Translation: 212078D Completely impacted tooth in bone SNODENT Buccal Gingiva: targetSiteCode: 16811007Buccal mucosa SNOMED CT Translation: 109364D Buccal mucosa SNODENT Code: 722192005 Localized swelling SNOMED CT Translation: 212078D Localized swelling SNODENT
Dental Service Request | ServiceRequest.priority ServiceRequest.reasonCode ServiceRequest.occurence | Plan of Treatment Section (V2) | Planned Encounter (V2) | CDT D3330 endodontic therapy, molar tooth (excluding final restoration)
US Core Profiles |  |  |  |
US Core Condition | Condition.code Condition.body SiteCondition.verification StatusCondition.category | Problem Section (entries required) (V3) | Problem Concern Act (V3) / Problem Observation (V3) | Value: 38341003 Hypertensive disorder (disorder) SNOMED CT Translation: 175027D Hypertensive disorder (disorder) SNODENT Value: 46635009 Type 1 diabetes SNOMED CT Translation: 175321D Type 1 diabetes SNODENT
US Core Encounter | Encounter.status Encounter.period | US Realm Header | componentOf / encompassingEncounter | Performed Mar 20, 2020 9am EST CDT D0140 limited oral evaluation - new or established patient
US Core MedicationRequest & Medication | Medication.code MedicationRequest .dosageInstruction | Medications Section (entries required) (V2) | Medication Activity (V2) / Medication Information (V2) | 314076 Lisinopril 10 mg Oral Tablet RxNorm 197650 erythromycin 500 MG Oral Tablet RxNorm 310965 ibuprofen 200 MG Oral Tablet RxNorm 313782 acetaminophen 325 MG Oral Tablet RxNorm
US Core AllergyIntollerance | AllergyIntollerance.code | Allergies and Intolerances Section (entries required) (V3) | Allergy Concern Act (V3)/ Allergy - Intolerance Observation (V2) | 7980 Penicillin G (Ingredient) RxNorm
US Core Vital Signs Observation | Observation.component.value | Vital Signs Section (entries required) (V3) | Vital Signs Organizer (V3) /Vital Sign Observation (V2) | Temp: 99 deg FBP 130/86 Pulse 92 bpm
US Core Patient | Patient.name Patient MRN (identifier) Patient.address Patient.telecom Patient.birthDate Patient.genderPatient.us-core-ethnicity(extension) Patient.us-core-race (extension) | US Realm Header | recordTarget/patientRole | Patient A MRN: 2020515 123 Test. Dr. Denver CO 80204 phone: (123)456-7890 email: testA@email.com 01-01-1990 Male Not Hispanic or Latino White
US Core Procedure | Procedure.code Procedure.outcome | Procedures Section (entries optional) (V2) | Procedure Activity Observation (V2) | Code : D0220 Intraoral - periapical first radiographic image CDT (Tooth #29) targetSiteCode: 8873007 Permanent lower right second premolar tooth SNOMED CT Translation: 161412D Permanent lower right second premolar tooth SNODENT Code: D0230 Intraoral - periapical each additional radiographic image CDT (Tooth #30) targetSiteCode: 28480000 Permanent lower right first molar tooth SNOMED CT Translation: 160770D Permanent lower right first molar tooth SNODENT Code : D0460 Pulp vitality test CDT (Tooth #30) targetSiteCode: 28480000 Permanent lower right first molar tooth SNOMED CT Translation: 160770D Permanent lower right first molar tooth SNODENT
US Core Organization | Organization.identifier:NPI Organization.active Organization.name | US Realm Header | custodian / assignedCustodian / representedCustodianOrganization | Name = Good Oral Health Clinic NPI = 1316452726 Address = 54321 Main Street, Fairfax, VA, 22031
US Core Practitioner | Practitioner.identifier:NPI Practitioner.name Practitioner Organization | US Realm Header | author/ assignedAuthor | NPI = 1034567384 Name = Dr. Drew Dentist Org = Good Oral Health Clinic
US Core PractitionerRole | PractitionerRole.organization PractitionerRole.code | US Realm Header | author/assignedAuthor/code | Healthcare Provider Taxonomy (HIPAA) 122300000X Dental Providers; Dentist
C-CDA on FHIR Based Profiles (Referral Note) |  |  |  |
Dental Referral Note |  | Chief Complaint Section | N/A | "Pain in lower right Quadrant"
Dental Referral Note | Composition.section.title = "Assessment Section" | Assessment Section | N/A | #30 pulpal necrosis and periapical pathosis with draining fistula. Clinical impression is that possible vital pulp remnants remain. #30 possible cracked DB cusp; rule out cracked tooth. Clinical impression is that tooth is restorable. #29 D caries lesion. On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration; #32 impacted with possible full boney impaction. One cm swelling present on buccal free-gingival around #29 and #30 with sinus tract present #30B. Periodontal pocket depth WNL.
Dental Referral Note | Composition.section.title = "History of Present Illness Section" | History of Present Illness Section | N/A | One month ago, pt. reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion). Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. He is able to eat regular food but only chews on the left side. He takes 400 mg ibuprofen every 8 hours for pain. His last dose was 2 hours prior to this visit.
Dental Referral Note | Composition .section .code =’43241-9’ | Reason for Referral Section (V3) | N/A | "Referral to endodontist for evaluation of #30 and endodontic therapy. (D3330) Suspect irreversible pulpitis with necrotic pulp and periapical pathosis. Tooth is restorable despite possible incomplete fracture DB cusp #30."
Da Vinci Profiles |  |  |  |
HRex Coverage | Coverage.status Coverage.payor | Payers Section (V3) | N/A | Aetna Comprehensive Medical /Dental Insurance

### Scenario 4: Dental (Endodontist) to Dental (General Dentist) Consult Note

Patient A was experiencing pain that started two weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. He is able to eat regular food but only chews on the left side. He takes 400 mg ibuprofen every 8 hours for pain, and his last dose was 2 hours prior to this visit. He visited his general dentist and was referred to Endodontist.

Previous medical and dental history verified by Endodontist: One month ago, patient reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion). Previous Medical History and Allergies from referring dentist:

- Medical History: Patient A has a history of hypertension and is taking Lisinopril 10 mg tablet once daily. Patient is also on erythromycin 500 mg every six hours for the infection and taking ibuprofen and acetaminophen as needed for pain.
- Allergies: Patient is allergic to penicillin.

Endodontist also verifies intraoral and paraoral findings from referring Dentist. At the end of the visit, a Dental Consultation Note is generated including medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations and sent from the Endodontist to the General Dentist.

Capability Statement References: Dental specialist office system is the Document Source (i.e., server) that generates the Dental Consult Note and the general Dental office application is the Document Consumer (i.e., client) that consumes the Dental Consult Note.

Verified suspected irreversible pulpitis #30 with necrotic pulp with PAP mesial root accompanied by draining sinus tract on B. No vertical fracture of root apparent during endodontic therapy.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 4: Dental (Endodontist) to Dental (General Dentist) Consult Note.

FHIR Resource/Profile | FHIR Data Element | CDA Section | CDA Entry | Data Values
--- | --- | --- | --- | ---
Dental-Specific Profiles |  |  |  |
Dental Condition | Condition.verficiationStatus Condition.category Condition.code | Problem Section (entries required) (V3) | Problem Concern Act (V3) /Problem Observation (V3) | Code: 109600005 Irreversible pulpitis (disorder) SNOMED CT Translation: 125784D Irreversible pulpitis (disorder) SNODENT targetSiteCode: 28480000 Permanent lower right first molar tooth SNOMED CT Translation: 160770D Permanent lower right first molar tooth SNODENT
Dental Finding | Observation.code Observation.value | Dental Findings Section | N/A | Performed transillumination and dye tests (blue dye) within pulp chamber during endodontic therapy and saw no evidence of cracks. Exposed one diagnostic periapical radiograph and confirmed radiographic findings above.
Dental Service Request | ServiceRequest.category ServiceRequest.code | Plan of Treatment Section (V2) |  | Puff of sealer noted around M root; monitor for the next year, and, if sealer does not resorb, consider apicoectomy.
US Core Profiles |  |  |  |
US Core AllergyIntollerance | AllergyIntollerance.code | Allergies and Intolerances Section (entries required) (V3) | Allergy Concern Act (V3) / Allergy - Intolerance Observation (V2) | 7980 Penicillin G (Ingredient) RxNorm
US Core Encounter | Encounter.status Encounter.period | US Realm Header | componentOf / encompassingEncounter | Performed Mar 22, 2020 9am EST CDT D3330 - endodontic therapy, molar tooth (excluding final restoration)
US Core MedicationRequest & Medication | Medication.code MedicationRequest .dosageInstruction | Medications Section (entries required) (V2) | Medication Activity (V2) / Medication Information (V2) | 993836 Acetaminophen 300 MG / Codeine Phosphate 30 MG [Tylenol with Codeine] RxNorm
US Core Procedure | Procedure.code Procedure.outcome | Procedures Section (entries optional) (V2) | Procedure Activity Observation (V2) | CDT D3330 endodontic therapy, molar tooth (excluding final restoration)
C-CDA on FHIR Based Profiles (Consult Note) |  |  |  |
Dental Consult Note | Encounter.reasonReference Encounter.priority | Reason for Visit Section |  | Referral for pain lower RQ, points to #30. Evaluation of #30 and endodontic therapy.
Dental Consult Note | Composition.section.title = "Assessment Section" | Assessment Section | N/A | Verified suspected irreversible pulpitis #30 with necrotic pulp with PAP mesial root accompanied by draining sinus tract on B. No vertical fracture of root apparent during endodontic therapy.
Dental Consult Note | Composition.section.title = "History of Present Illness Section" | History of Present Illness Section | N/A | Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. He is able to eat regular food but only chews on the left side. He takes 400 mg ibuprofen every 8 hours for pain. His last dose was 2 hours prior to this visit. He visited his general dentist and was referred to Endodontist.