Accurate dental charting is essential for both patient care and legal protection. The January 2025 Dental Board meeting provided valuable insights into documentation best practices, diagnostic protocols, and risk management strategies.
Below are the key highlights that every dentist should consider to improve their progress note charting and reduce malpractice risks.
Dental Board Highlights – January 2025
1. Perio Probes and Extraction Documentation
For cases where a tooth is clearly non-restorable based on radiographic evidence, periodontal probing is not required. However, for all other extractions, dentists must record pocket depths for each removed tooth to ensure complete and defensible documentation.
2. Informal Assessments and Charting Risks
Patients often ask for a dentist’s informal opinion on potential treatment needs before a full work-up is performed. One case involved a dentist who noted a patient needed four crowns based on an informal chairside assessment. This progress note charting was then used to generate a written treatment plan without supporting diagnostic evidence (e.g., X-rays, periodontal probing, or a formal diagnosis).
The board’s consultant flagged this as an inadequate evaluation due to the lack of diagnostic records. However, the board ultimately dismissed the case. To avoid similar scrutiny, dentists should use terms like “courtesy assessment” or “preliminary diagnosis” when making informal observations in progress notes. This helps clarify that a full diagnostic evaluation is still required.
3. Nightguards vs. Composite Build-Ups for VDO Changes
For patients needing vertical dimension of occlusion (VDO) adjustments, the board reaffirmed that a nightguard is the preferred method over composite build-ups. Bruxers, in particular, can easily remove composite material. Additionally, when altering VDO by 2mm or more, a trial period of two to six months is recommended before proceeding with permanent restorations.
Enhancing Dental Charting with Lightning Dental Charts
Accurate dental charting isn’t just about compliance—it’s a safeguard against malpractice risks. As board cases show, even small documentation errors can lead to legal scrutiny. That’s where Lightning Dental Charts comes in.
Our SaaS dental charting software helps dentists create legally robust progress notes in minutes. Designed with input from a leading dental malpractice defense attorney, our system ensures your dental progress notes meet legal and clinical best practices. With step-by-step guided templates and a voice-powered AI agent, Lightning Dental Charts reduces documentation time while strengthening malpractice defense.
Why Dentists Choose Lightning Dental Charts
✅ Pre-populated charting templates to ensure complete documentation
✅ Voice-powered AI charting for hands-free, efficient note-taking
✅ Designed to reduce malpractice risk with legally sound progress notes
By refining your dental charting approach with Lightning Dental Charts, you can streamline documentation, improve legal defensibility, and focus more on patient care.
Ready to simplify and strengthen your dental charting? Try Lightning Dental Charts today.
For more updates on dental progress note charting and risk management best practices, stay tuned to our blog!
