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The Business of Dentistry: Patient Records and Records Management

Natalie Kaweckyj, LDARF, CDA, CDPMA, COA, COMSA, MADAA, BA; Wendy Frye, CDA, RDA, FADAA; Lynda Hilling, CDA, MADAA; Lisa Lovering, CDA, CDPMA, MADAA; Linette Schmitt, CDA, RDA, MADAA; Wilhemina Leeuw, MS, CDA

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administrator, practice – One who manages the staff of a practice.

apex, apical – The very tip of a tooth’s root.

arch – Pertaining to the upper (maxillary) or lower (mandibular) jaw.

bicuspid/premolar – The teeth located between the canines/cuspids and the first molars in each quadrant; only found in the permanent dentition.

canine/cuspid – A tooth with one cusp located between the lateral incisors and first premolars in each quadrant.

caries – An infectious disease caused by bacteria in dental plaque that destroys tooth structures; also known as tooth decay or dental cavities.

carious lesion – An area of decay on a tooth.

cavity – A hole or decay lesion in a tooth.

cementum – The tissue covering the root of a tooth.

central incisor – Two front teeth on both upper and lower jaws.

cingulum – A smooth, rounded bump on the cervical third of the lingual surface of anterior teeth.

clinical record – The patient record that includes all services rendered, treatment notes, treatment correspondence and medical and dental histories.

current dental terminology (CDT) – A list of descriptive terms and identifying codes developed by the ADA for reporting dental services and procedures to dental benefit plans.

cusp – Elevation or mound on the biting surface of a tooth.

custom software – Applications software that is developed by the user or at the user’s request.

database management – Computer software application used for organizing, entering, storing, and retrieving information in formats and orders specified by the user.

deciduous (primary) teeth – The first set of teeth; also known as milk teeth.

dental charting – The documentation of existing restorations and conditions of the oral cavity.

dentin – The tissue of a tooth that comprises the main inner portion of the tooth; it is covered by cementum on the root and enamel on the crown.

dentition – Set of teeth; the natural teeth in position in the dental arches.

denture – A removable prosthesis that replaces two or more teeth in an arch; may replace all teeth.

distal – The proximal surface of a tooth that is away from the midline.

downloading – Transferring information received over a communications network to a software program so that it can be printed out or processed at an individual workstation.

electronic calendar/calendaring software – A computerized system for recording appointments, setting up meetings and scheduling other daily, weekly or monthly activities.

enamel – Substance that covers the anatomic crown of a tooth to protect the dentin; the hardest substance in the body.

facial – The surface of a tooth that faces the lips or cheeks; includes the labial and buccal surfaces.

factitious – Produced by humans rather than natural forces.

HIPAA – The Health Insurance Portability and Accountability Act requires that the transactions of all patient healthcare information be formatted in a standardized electronic style.  In addition to protecting the privacy and security of patient information, HIPAA includes legislation on the formation of medical savings accounts, the authorization of a fraud and abuse control programs, the easy transport of health insurance coverage and the simplification of administrative terms and conditions.

incipient caries – Beginning caries that has not yet broken through the enamel into the dentin.

incisal – Cutting or biting edge of anterior teeth.

interproximal – Between the proximal surfaces of adjacent teeth.

labial – The surface of anterior teeth facing the lips.

lateral – To the side; toward the outside or away from the midline.

lateral incisor – Tooth distal to the central incisor in each quadrant; there are four lateral incisors present in the permanent and primary dentitions.

lingual – The surface of a tooth that faces the tongue.

malocclusion – Any deviation from normal occlusion; may involve one tooth, several teeth or an entire arch.

mandibular – Pertaining to the lower jaw.

mastication – The act of chewing.

maxillary – Pertaining to the upper arch.

mesial – The surface of a tooth that faces the midline.

midline – An imaginary vertical plane that divides the body into equal right and left halves.

numbering, International Standards Organization/Fédération Dentaire Internationale – A two-digit system of designating teeth for the permanent and primary dentitions.  The first digit denotes the quadrant; the second digit denotes the tooth number.

numbering, Palmer – Numbering system in which the mouth is divided into quadrants and the teeth are assigned a number from 1-8 beginning with the central incisor in the permanent dentition.

numbering, Universal – Numbering system where teeth are assigned a number from 1-32 beginning with the maxillary right third molar in the permanent dentition.

occlusal – The biting surface of a posterior tooth.

occlusion – The contact between the maxillary and mandibular teeth in any functional relationship.

overbite – Excessive vertical overlapping of the maxillary incisors over the mandibular incisors.

overjet – Excessive horizontal overlapping of the maxillary incisors over the mandibular incisors.

PHI – acronym associated with privacy; stands for protected health information.

proximal – The surface of a tooth that is adjacent to another tooth; the distal or mesial surface.

quadrant – One-fourth of the mouth; half of the maxillary or mandibular arch.

succedaneous – Permanent teeth that replace primary teeth.

tooth, eye – Layman term for canine/cuspid.

tooth, wisdom – Layman term for third molar.

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