1 Introduction

The general dentistry set of diagnostic terms is designed to provide dentistry with a relatively easy to implement set of terms that covers the vast majority of care provided in the dental field.  It does not attempt to meet the needs of dental subspecialties but may prove to do so for a significant amount of the care provided by these specialists.

This document provides information about the general dentistry diagnostic term set.  It does not include a discussion or recommendation regarding the broader set of all SNOMED CT terms that are related to dentistry.

2 Background

With few exceptions, the dental profession has rarely used or recorded in any structured way diagnostic terms.  While dentists may document a diagnosis or rationale for treatment in their clinical or progress notes, identifying the treatment provided continues to be the area most frequently documented in a structured form.  This may be due to requirements for reimbursement purposes.

2.1 Scope

The purpose of the subset is twofold.  First, it is designed to identify a set of frequently used diagnostic related terms for general dentistry.  As dental clinicians only infrequently use structured terms (whether while being educated or after entering clinical practice) for diagnosis, a simple set may allow for better understanding of the use of dental diagnostic codes.  Second, a small set may allow EDR vendors and the dental payer community to more quickly and inexpensively implement tools that will allow for their use.

Examples:

Data entry- Direct entry of SNOMED CT concepts using the GD term set

During a patient encounter, the dental clinician identifies a problem or need.  The clinician then enters the problem/disorder/finding into a “diagnosis” field and the EDR then provides a list of the most frequent SNOMED CT terms that the clinician can then use to select the best match from the GD term set.  Alternately, a set of “pick lists” could be used that would take a clinician through a hierarchy of one to several different levels that would result in the best possible match for the identified condition.

Referral/Transfer of care

A general dentist may wish to refer the patient to a specialist colleague.  The general dentist would enter the information regarding the problem/disorder/finding using a SNOMED CT term from the GD term set.  An HL7 message is then constructed containing the identified SNOMED CT concepts from the GD term set.  This would allow the specialist to have the information and possibly differential diagnosis from the general dentist.  This should reduce confusion and hopefully save the patient some time and reduce repetitive services.

Constraint of terminology for population and subpopulation analysis

While one can make a compelling case for a more granular and therefore larger term set, the infrequent  use of terms to date in dentistry potentially limit its value until dentists and other dental clinicians better understand the use of, purpose of, and proper identification of diagnostic concepts.

Dentistry has some general disease categories.  Dental caries, gingival diseases including periodontal, and endodontic diseases account for the vast majority of treatment procedures provided by dentists when treating diseases.  Further, it will take dentistry some time to get to the point where virtually all dental visits result in the assignment of a rationale or structured term for the visit.

Initially, in order to provide some level of data aggregation, less granularity may allow for the development of CDS tools and other forms of evidenced based tools for assisting in the determination of care plans.

3 Motivation

Recognizing the value of identifying a diagnosis and relating it to treatment for the improvement of outcomes and for development of decision support tools (CDS) by others in the medical profession, a group of members of the IHTSDO Dentistry SIG located in the United States began work on identifying a set of diagnostic terms that had the potential for being easily understood by all dental clinicians, easy to implement for electronic records system vendors, adaptable to current clinical workflows, and has the potential to support the development of CDS tools as well as relate diagnosis to treatment and even outcomes of care.

Over a period of approximately one year and with the cooperation of the payer community in the United States and two organizations that have been using diagnostic coding in dentistry for a significant period of time, the US effort resulted in a preliminary set of SNOMED CT terms that has was then been reviewed by the Dentistry SIG to ensure international relevance.  All comment received prior to the April 2016 meeting of the Dentistry SIG in London was positive.  At this meeting the Dentistry SIG recommended that the IHTSDO move forward with further development to make this work an official subset of SNOMED CT.  In parallel, the SNOMED CT editors worked to include required new concepts in SNOMED CT so that all was completed for the July 2016 International release.

4 Design

4.1 Version

The version of SNOMED CT is July 2016 International Release

4.2 Ownership

Whilst IHTSDO are the owners of SNOMED CT, clinical validation and ownership is provided by the International Dentistry SIG

4.6 Cardinality

5 Content

The general dentistry diagnostic subset (GD subset) primarily contains SNOMED CT findings.  Most of these findings are disorders, but some of the terms are other types of findings dental clinicians may document as the rationale for providing a specific treatment or sequence of care.  Further, the set includes a few attributes that allow clinicians to better define the extent of disease for the most common dental disease, caries. The entire subset consists of less than 250 terms as of April 2016.

The subset also includes terms that allow a dental clinician to provide a rationale for patients seeking preventive services that have no chief complaint.  In many countries, dentistry recommends periodic preventive visits that often include some limited treatments such as prophylaxis as a tool to reduce the risk of periodontal disease and obtaining radiographs as a method to potentially identify dental caries at an earlier stage, allowing for a more limited intervention.

This subset was designed using some very basic principles. It used the limited information available from sources known to be using diagnostic codes in dentistry and compared them to services actually provided.  Developers also used terms already available in SNOMED CT when the term could be used to represent clearly language (interfaces) most often used within the profession in the USA and, where known, other parts of the world.

5.1 Content Changes

Content changes for General Dentistry Diagnostic Refset for (Release date).

N/A for the October 2016 Release.

6 Maintenance

6.1 Responsible Clinical Group

The IHTSDO Dentistry SIG will be responsible for the maintenance, review and updating of the General Dentistry Diagnostic Refset.

6.2 Maintenance Policies

6.2.1 Guiding Principals

The defined purpose will not change with a goal of graceful evolution.

6.2.2 Frequency

The will be delivered XXX

6.2.3 Schedule

The Refset will be reviewed on an annual basis at the Fall IHTSDO meeting

6.2.4 Verification

7 Implementation

With a very limited history of implementation of any diagnostic terms in dentistry and the fact that there are numerous different electronic dental records (EDR) system vendors worldwide using different methodologies of data structuring, databases, visualization, and workflow design, it is likely that there may be several unique and functional approaches to implementation of the GD subset.  Additionally, the varying payment mechanisms in different countries may have different needs and set different requirements as they become more involved in obtaining and using the data.  The Dentistry SIG would appreciate the opportunity to see and provide feedback to the vendors as they begin adding structured diagnostics to their systems

8 Obtaining the Release

The SNOMED CT General Dentistry subset is available from the IHTSDO and is maintained and updated in line with the SNOMED CT International release which is currently 6 monthly.

Access within IHTSDO member countries is provided by the Member National Release Centre in each country, via the relevant Member page. Affiliates of IHTSDO in non-member countries can access the subset through their Member Licensing and Distribution SERVICE (MLDS) account. Please contact info@ihtsdo.org for more information if required.

9 Feedback

As mentioned previously, dentistry and dental clinicians only infrequently use any form of diagnostic terminology. The number of user interfaces is, therefore, very limited.  Currently there has been no usability testing completed of this subset.

It is also recognized that this is not an exhaustive set of terms dental clinicians might use.  It may not be suitable for dental specialists or general dentists who limit their practices to such areas as dental implants or treatment of specific conditions such as sleep apnoea. It is expected that, as adoption increases, the subset will need updating.  It may also be necessary to develop subsets for the limited number of recognized dental specialties.

Thus feedback is welcome and should be sent to info@ihtsdo.org. This feedback may include any issues relating to implementation, suggestion for future content or general comments regarding the subset.