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Abstract

Background: dental documentation is essential for the representation and communication of dental information amongst researchers and practitioners. Dental documentation has to provide the respective means for (a) the representation of the patient status’ and (b) the possible actions. Methods: the consistency of German definitions currently used for dental findings is evaluated by projecting well known examples onto problem axes like “existence of a structure” and “condition of a structure”. Results: it can be shown that current German dental terminology does not support an unambiguous documentation for any situation in dental practice. In some cases, Multiple aspects are merged in several finding statements and make a stringent derivation of the treatment planning difficult. Conclusions: dental documentation in Germany can in some aspects be improved with respect to (a) precision, (b) expressiveness, (c) simplicity and (d) reproducibility. The main axes of dental documentation are enumerated in preparation of a future top-down approach. Clinical Implications: an optimised finding scheme can enhance the communication amongst researchers and practitioners and thus is supposed to improve the treatment quality in the long run.