Published in IVIS with the permission of the AAEP Close this window to return to IVIS

Computerized Dental Charting

Edward T. Earley, DVM

Authors address: Laurel Highland Farm & Equine Services, LLC, 2586 Northway Road
Ext., Williamsport, PA, 17701; E-mail: etearley@earthlink.net.

Introduction

As the standards in Equine Dentistry are being raised, the need for advanced record
keeping and dental charting closely follows. Advanced Dental Charting may include
images such as color illustrations, incorporated photographs and radiographs. Detailed
record keeping in each of the sub-disciplines is becoming the expected “standard of
care”.

The aspects of computerized record keeping that will be discussed include dental charting
and documentation, taking and processing dental photographs and incorporating
radiographs. Other topics that will be briefly discussed include utilizing a technician and
file synchronization.

The goals of current record keeping standards can be easily met by computerization.
These goals should include:

1) To have an organized documentation of the equine patient and of the dental

procedures performed.
2) The dental chart should be easily readable by other physicians and by the client.
3) Images such as photographs, radiographs and CT’s should be easily incorporated
into the dental chart.
4) The dental chart should be reproducible, easy to file, easy to access and printable.
5) The time and effort to create a dental chart should not be overbearing.
6) A back-up and file transfer system should be established.

Equipment

The equipment needed is readily available at most computer or office supply stores. The
equipment list includes:

1) A laptop that has a fairly strong RAM (Random Access Memory) of at least 1 GB
and a hard drive storage capacity of at least 80 GB.
2) A tablet system for color illustrations and drawingsa.
3) A digital camera that is capable of taking at least a 5 mega pixel image.
4) File management softwareb.
5) Image editing softwarec.
6) A compact combination printer that can print, scan and copy.
7) Optional equipment would include a radiographic converting system,d,e intra-oral
camera, synchronizing software.e,f

A. Dental Charting and Documentation

The process of dental charting and documentation involves three processes 1)
creating a master template of the dental form, 2) creating a master template of a
dental work sheet and 3) incorporating the findings from a thorough dental exam.

1. Creating a master template

The first step towards a computerized charting system is to create a master

template. The template can be multiple pages with locations for photographs,
diagrams for color drawings, tables and charts for highlighting pertinent
information and forms for text entry. Using a template helps to streamline the
process of entering images, drawings and data (see Appendix for examples of
blank templates).

The areas of the form designated for photographs can be broken down into
sections of pre and post dental work. Try working with a few dental photographs
in advance in order to make an estimate of a standard size that will be utilized
within the dental form.

Drawing over a chart is useful in clarifying procedures and dental abnormalities.

Utilizing color drawings helps to distinguish the abnormality from the original
dental chart.

The written section of the dental form can be created as a dental chart with a
section for each discipline. Each section can have designated lines as discernable
spaces allowing for rapid and organized data entry.

It is important to establish which file format will be used at the time of creating
the master template. Some formats will allow for stacking of the pages of the file
(PDF and PaperPort) while others will only bundle the data into a folder (JPEG
and TIFF).

2. Creating a master worksheet

A worksheet is very useful for entering data while working on the horse. It should
be easy to organize findings in a quick an efficient manner within each discipline
and each arcade. See Fig. 1 as an example of a work sheet.
Figure 1.
 3. Incorporating a thorough dental exam

If the dental examination process is structured, it becomes less likely that parts of
the exam will be missed. It is helpful to have the worksheet match the dental chart
so that the findings can be easily transferred. Below is an example of how the
exam could be broken down:

a. Physical exam
b. Dental Grading
c. Evaluation of excursion and contact pre and post dental work
d. Occlusal abnormalities
e. Periodontal exam
f. Endodontic exam
g. Caries exam

B. Dental Photographs

Dental photographs can be easily added to the dental charting system. In order to
achieve this, a very minimal understanding of digital cameras and photographic
software is needed. Below is an outline of some basic steps that could be used in
developing a technique when working with oral photographs.

1. A short review of standard Digital Cameras and image storage.

a. Digital camera – preferably a minimum of a 5.0 Mega Pixel capability
(ex. 2592 pixels x 1944 pixels) at 72 pixels/inch.
b. Find a camera with a small lens size to fit between the incisor plates of
the speculum.

c. Look for a camera that has the flash close to the lens so that the flash
won’t be obstructed by the cheek or speculum
d. An automatic focus illuminator is very helpful for focusing within the
oral cavity and using a flash.
e. Consider the ease of transferring images to the computer. If a memory
stick/chip matches the computer it saves time using wires and adaptors
2. Techniques in taking straight “whole mouth” intra-oral views.
a. It seems to be easiest to break “whole mouth photos” into right (200
and 300 arcades) and left (100 and 400 arcades) views. See Figs. 2 and
3, respectively.
b. If you are right handed, use your left hand to retract the horse’s right
cheek or tongue while your assistant works on the left side of the
horse. When photographing the right arcades, hold the horse’s right
cheek out with your left hand and have your assistant hold the tongue
off to the left side of the horse (Fig. 2). Reverse the process with your
assistant for the left arcades (Fig 3).
c. Hold the camera just at the level of the incisors making sure to get the
lens and flash between the speculum plates.
Figure 2. Figure 3.

d. Have the camera set in flash or "synchro" flash and automatic focus
mode by utilizing the focus illuminator.
e. Take several pictures to ensure chances of obtaining a good
photograph for the dental chart.

3. Using indirect photography with intra-oral mirrors.

a. This technique is useful when trying to focus on a specific problem
involving a single tooth (ex periodontal pocket, fractured crown, etc.)
b. Have the mirror warm so as to avoid fogging. Anti-fogging products
applied to the mirror are also helpful.
c. Place the mirror over the site/tooth and angle the mirror so that you
have a good view. Place the camera in an unobstructed view of the
mirror using the automatic focus, focus illuminator and flash.
d. Try not to use the zoom function as this could compromise your focus
of the image. The macro image mode will open the aperture and slow
the shutter speed. This will cause an image to have less depth of focus.
With a 5 mega pixel image, you can always enlarge the image on the
computer utilizing a photo editing software program.c The image will
be more versatile if it has a good depth of focus (Figs. 4 and 5).

4. Other options with intra-oral cameras.

a. An intra-oral camera as used in small animal and human dentistry.
b. An adapted laparoscope may be used.
5. Importing the images to the computer.
a. This can be done by attaching a USB wire to the camera, a chip reader
or placing the chip directly into the computer.
Figure 4.

Figure 5.
 6. Sizing the images and processing them to the dental chart.
a. After the images have been moved to the patient’s file, use the
thumbnails to view the best images.
b. Select the images desired for the dental chart by tagging them with the
mouse (Right click) while holding down the “Ctrl” (Control) tab.
“Copy” and “Paste” the whole group of selected images. Use the
copied versions to work with so that you don’t lose the originals.
c. Using the same technique, select all of the copied images and send
them to photograph editing software.c
d. With the editing software, the images can be cropped and resized to fit
the templates on the dental form.
e. Save the finished images back to the patient’s file.
f. Copy and Paste the images to the Dental record.
g. If the dental chart is in a format that is stackable (such as PDF or
PaperPort), the photographs can still be pasted to the dental form even
though they are a JPEG format. By doing this the photos can be
stacked. If the dental form is in a JPEG format, the form and images
will be bundled into a folder but not stacked. The latter is more
cumbersome when trying to store and review cases.
C. Dental Radiographs

The incorporation of radiographs with the dental chart is not limited to Computed
Radiography (CR) or Direct Radiography (DR). With minimal effort and expense
it is possible to digitize standard radiographs. With all three applications (CR, DR
and standard radiographs), once the image has been converted to a “JPEG”
format, it can be managed similar to photographs.

1. Methods of digitizing radiographs.

a. The digital camera can be utilized for digitizing radiographs. This is
accomplished best by having the film on a viewer in a dark room and
putting the camera on a small tripod in front of the viewer. If possible,
switch the camera to black and white mode and turn off the flash. Try
to position the camera so that the whole image is filled with the
radiograph. If the camera does not have a black and white function, the
images can still be switched to black and white with editing software.c
b. A “RDC” (Radiograph Digital Converterd) unit utilizes the same
principles as above but does so in a controlled environment. The
digital camera is mounted in the top of an enclosed box and the
radiographs are placed at the bottom of the box above a lighted viewer.
The image is recorded as a black and white image and stored to the
patient’s file. An advantage with the “RDC” unit is that it includes an
editing software package. The editing package has many of the same
features as the software found with “CR” (Computed Radiography)
units. These features include labeling, zoom, contrast, darkness, sizing
and angle measurements.
 Figure 6.

c. A radiographic scanner could also be utilized to convert the radiograph

to a digital image. The editing software is similar to what is used in the
“RDC” and “CR”units.
d. If Computerized Radiology (CR) or Direct Radiology (DR) is used,
the images can be saved to the patient’s record in a JPEG format.

2. Incorporating the images of the radiographs to the dental record.

a. Once the images of the radiographs have been sent to the patient’s file,
they can be worked with in a similar fashion as the photographs. There are
two options at this point to make the radiographs stackable. The first is to
resize and paste the image to the dental template. The second is to convert
the radiographs to a format that is stackable (PDF or PaperPort). By doing
one of these two steps the radiographs become much easier to manage
when filing and reviewing records.
b. When radiographs are attached to the dental record, it may be more
useful to give the client a copy of the file on a CD (Compact Disc) rather
than printing it out. The radiographs can drain the black ink from a printer
in a hurry.

D. Other topics that help with implementing a computerized charting process in practice.

1. Utilizing a technician.

A technician can be taught to do everything that has been covered in this

paper. The computerized charting process may seem involved with first
impression, however, through repetition it can become a very routine
procedure. When training a technician, it is helpful to initially create a
 “cookbook” document that details the process in a “step by step” fashion. The
documentation makes it easier for future technicians to be trained by the
current staff.

2. Synchronizing files with a main computer back at the clinic.

a. The Briefcase systeme is a functional system when the file size is small
(<2 GB). As the file grows, the synchronizing process tends to take
additional time and there is more opportunity for missed and/or
orphaned files.

The Briefcase works on the concept that there is a master file and a
synchronized file. The synchronized file has fewer options available to
work with as compared to the master file. An example would be that it
is not possible to copy data to a synchronized file but rather the data
must be moved to the file.

b. There are software programs available that handle larger volumes of

files in a shorter period of timef. A software program allows the files to
be “master files” on both sides without any compromise in function.
The synchronizing is very streamlined and efficient with data moved
in both directions simultaneously. As an example, 25 GB of data
between two computers can be updated, copied and synchronized in 3-
4 minutes. Using the same data and computers, the Briefcase system
will take over 2 hours.

An additional advantage in using a software program for

synchronizing computers is that multiple computers may be used.
Every computer acts as a separate entity (as opposed to a master and a
synchronized file). By utilizing this concept, several laptop computers
can be matched to a single desktop computer and data can be moved
and updated between all of them with little time and effort.

Summary

As the “Bar” is raised in the “standard of care” for equine dentistry, so follows the need
for accurate and accessible dental records. Digital photography and radiology are two
very important tools utilized in equine dentistry. The incorporation of these modalities
into the dental chart is important for documentation, education, patient follow-up and
client awareness. A dental technician and synchronizing software will help to streamline
to total process.

Footnotes

a. Wacom Technology Corporation, Vancouver, WA, (800) 922-9348, Wacom

tablet, www.wacom.com.
b. ScanSoft Inc., Peabody, MA, (978) 977-2000, Paperport 10.0, www.Scansoft.com
c. Adobe Photoshop 6.0, Adobe Systems Inc.
d. Radiographic Digital Converter (RDC), Mast Technology, Garland Texas, 888-
484-9729, www.radiographconverter.com.
e. Microsoft windows – Briefcase system.
f. FolderMatch v3.3.7, by Salty Brine Software, www.saltybrine.com.
Appendix
_______________________________________________________________________________
American Association of Equine Practitioners - AAEP -
Focus Meeting, 2006 - Indianapolis, IN, USA
This manuscript is reproduced in the IVIS website with the permission of AAEP www.aaep.org