Providing clear information for patient and provider.

Our medical colleagues have been capturing the causes of death for centuries using standardised diagnostic terms. The first international conference to revise the International Classification of Diseases (ICD) was convened in 1900. In 1948, the World Health Organisation (WHO) took responsibility for the now renamed International Classification of Diseases, Injuries, and Causes of Death with the sixth edition. The WHO expects to launch ICD-11 in 2020. Oral health diagnoses are classified in the early and current revisions of ICD. However, they are not granular enough and difficult to find throughout the ICD volumes. Additionally, the dental profession does not mandate documentation of a dental diagnosis as part of the billing process and consequently, diagnoses are not captured in a structured format. Hence, until recently dentistry did not capture why a tooth becomes non-vital or why it had to be extracted, much to the disadvantage of clinical dentistry, dental public health and dental quality improvement efforts.

Several attempts to address this problem have been made throughout the years, including the development of the Toronto codes in 1999 and the Systemised Nomenclature of Dentistry (SNODENT) by the American Dental Association (ADA). SNODENT, which is integrated into SNOMED, has proved largely ineffective as a chair-side terminology, not least because it is composed of more than 7,000 terms, is not widely available and is yet to be finalised.

To meet the need for a comprehensive yet concise set of dental diagnostic terms, a happy medium between ICD sparseness and SNODENT/SNOMED enormousness, an academic workgroup came together in 2009 to create and implement the EZCodes dental diagnostic terminology, later renamed Dental Diagnostic System (DDS). Key motivators included the dire need for the dental profession to enter a diagnosis in the patient record that is clear and can be used to inform both the provider and the patient. A standardised terminology can capture a granular diagnosis in the electronic health record (EHR) that then helps inform the providers of the specific treatment procedures appropriate for the chosen diagnoses. For the patient it will specify information why a certain procedure is being done, by providing detailed reasoning behind each procedure. From an educational perspective, it allows faculty to create a diagnostic-centered academic approach that will facilitate students to learn.

Led by Dr. Elsbeth Kalenderian from Harvard School of Dental Medicine, an academic workgroup developed the first diagnostic interface terminology specifically applicable to the field of dentistry. The Dental Diagnostic System (DDS) – formerly known as EZCodes, contains dental diagnostic terms at the granularity level required by practicing dentist’s chair-side. Developing the DDS terminology was an iterative process that began with the University of California, San Francisco School of Dentistry’s Toronto Z skeleton, as it was representative of dental clinical practice. The Z Codes were based on the original Toronto codes proposed earlier, but never widely adopted. This Z skeleton was then populated with concepts from the American Academy of Periodontology, the American Board of Endodontics, UCSF own Z codes and International Classification of Disease terms to ensure adequate concept orientation. The first version of the DDS diagnostic terminology was produced following two rounds of discussion with domain experts and subsequent review by the workgroup. This produced DDS-2010 with 1,158 terms in 13 categories and 78 sub-categories. Subsequent revisions produced a robust DDS terminology with DDS-2015 consisting of 1589 terms, in 17 categories and 107 sub-categories.

Members of the workgroup include Drs. Joel White, Muhammad Walji, Oluwabunmi Tokede, Maxim Lagerweij, and Rachel Ramoni. All are united by a common goal to improve dental research, education and patient care by creating a go-to terminology for clinical and public health research. There were several considerations for the workgroup members to take into account during the process of developing a terminology that should be easy to use in the clinic and be usable for research through secondary data analysis. First and foremost, the team must ensure that clinicians use the standardised terminology consistently and accurately. Hence the DDS research team completes ongoing validation and measuring of DDS utilisation.

The DDS aligns dentistry with medicine, in terms of establishing standard clinical practice. Enabling diagnoses to be clearly recorded after examination and providing care is important to facilitating communication between clinicians, patients, epidemiologists, researchers and students. While the standardisation of dental diagnostic terminologies is of obvious benefit to dentistry, it is important that additional consideration is given to how the terminology will be shared. Facilitating and encouraging its use is key to the DDS realising its potential. With that in mind, NIH/NIDCR is supporting the development of the DDS implementation toolkit, which will enable the terminology to be rolled out to non-academic dental institutions and general practitioners.

Eighteen dental institutions from the US, Canada and Europe use the DDS for patient care, teaching and research. Ten additional schools are slated to implement the DDS terminology within the next year. Incorporated within axiUm, Exan Corporation’s dental EHR, the DDS is available to almost every dental school in the US. Two other EHR vendors are revising their HER interface in order to effectively upload the DDS. This as a result of pressure from their users who are concerned about government mandates to document a diagnosis as part of Medicaid reimbursement requirements. The DDS has been shown to be useful and accurate, and its terms are routinely paired with dental procedures providing a treasure trove of usable data on dental diagnosis and treatment for appropriateness of care and outcome research.

The DDS is a crucial component of the BigMouth Dental Data Repository (which houses data from six institutions with nearly 2 million patients). Structured data entry is essential for developing effective electronic data repository systems and helping clinicians and researchers use them in a meaningful way. With the creation of the DDS, the team has made this possible.

Dr. Elsbeth Kalenderian

Chair – Dept. of Oral Health Policy and Epidemiology

Chief of Quality – Harvard Dental Center, Harvard School of Dental Medicine

Tel: 1 617 432 4375


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