Dental Data Exchange
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Dental Data Exchange, published by Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/dental-data-exchange/ and changes regularly. See the Directory of published versions

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 B has a history of hypertension and takes Lisinopril 10mg tablet once daily. He is also taking Azithromycin in accordance with the current American Dental Association Clinical Practice Guidelines for the infection (since there will be a delay in definitive conservative dental treatment due to the referral, and he is allergic to penicillin), and alternating acetaminophen and ibuprofen as needed for pain control.

Patient B has a history of hypertension and takes Lisinopril 10mg tablet once daily. He is also taking Azithromycin in accordance with the current American Dental Association Clinical Practice Guidelines for the infection (since there will be a delay in definitive conservative dental treatment due to the referral, and he is allergic to penicillin), and alternating acetaminophen and ibuprofen as needed for pain control.

Dr. Dentist records Patient B’s diagnostic test results and clinical impressions and sends a referral to the endodontist for an evaluation and appropriate treatment for tooth #30. The 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.

Diagnosis for tooth #30: pulpal necrosis and chronic apical abscess (with a draining sinus tract). #30 has a potentially cracked DB cusp. Use of Tooth Slooth appeared to rule out vertical root fracture. Clinical impression is that tooth #30 is restorable with a good long-term prognosis. #29 D has a moderate active carious lesion. On exam of the lower right quadrant, tooth #30 was very sensitive to percussion and non-responsive to cold or EPT testing. Minor sensitivity to palpation elicited in this area, but pain experienced on biting with relief on opening for tooth #30. No evidence of new caries on distal. Missing tooth #28 was replaced with an endosteal implant with a porcelain fused to metal crown. Tooth #32 is impacted (possible full-bony impaction). Minimal swelling present on lower right buccal vestibule around #29 and #30 with sinus tract present on #30B. Periodontal probing depths in lower right quadrant were all less than or equal to 3 millimeters. Pt is taking Azithromycin (500 mg loading dose and 250 mg each day for 4 additional days) for the infection and alternating 600 mg of ibuprofen and 1000 mg of acetaminophen every 6 hours for pain and swelling.

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
308460 Azithromycin 250 MG Oral Tablet RxNorm
310965 ibuprofen 200 MG Oral Tablet RxNorm
198440 acetaminophen 500 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 chronic apical abscess with draining sinus tract.
#30 has a possible cracked DB cusp; ruled out vertical root fracture. Clinical impression is that tooth is restorable.
#29 D has an active moderate carious lesion.
On exam of the right lower quadrant, tooth #30 was sensitive to percussion with no response to cold or EPT. Mild sensitivity to palpation near #30 B, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal implant with porcelain fused to metal crown. #32 is impacted (possible full bony impaction). Minimal swelling present on buccal mucosa around #29 and #30 with sinus tract present #30B. Periodontal probing depths all less than or equal to 3mm.
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 an 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 B said the pain started a month ago, and worsened until the cold sensitivity went away about a week ago. He noticed a bad taste in his mouth about that same time. He is able to eat regular food but only chews on the left side. He takes 400 mg ibuprofen every 6 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 and treatment of #30. Diagnosis is necrotic pulp and chronic apical abscess #30. Tooth appears to be restorable despite possible incomplete crown fracture of DB cusp on tooth #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.