How To Read A Dental Prescription

prescription

an instruction written by a medical practitioner that authorizes a patient to be issued with a medicine or treatment

CONTENT OF A PRESCRIPTION :

  1. Clinic Name, Doctor’s name and qualification
  2. Patient’s Name, age, sex, Address
  3. Date, Clinic contact details
  4. Chief Complaint (C/C)
  5. Medical History
  6. Personal and family History
  7. Intra Oral Examination (IOE)
  8. Extra Oral Examination (EOE)
  9. Advice ( For blood investigations, radiographs, treatments like RCT)
  10. Diagnosis
  11. Treatment Done
  12. medicines
  13. Recall / future appointments

What is Chief Complaint (c/c) means ?

It is the first thing that is mentioned by the dentist in your prescription. The main concern of patient and what symptoms he/she tells to the dentist is written in chief complaint segment by the dentist in patient’s own words not in the medical terms or words. previous experiences of the same symptoms and treatment done for the same if it is.

In case of head injury history of unconsciousness, vomiting, bleeding will be recorded by the doctor in patient’s prescription.

example: patient c/o ( complaints of ) pain in lower right back teeth region since 3 to 4 days . pain started gradually but now it become severe and goes towards head.

What is Medical, Personal and Family History ?

doctor will ask the patient for any known medical condition (e.g. diabetes, hypertension, hyperthyroidism, asthma, epilepsy, anemia, platelet disorder, bleeding disorder, liver disease etc.) pregnancy, menstruation, lactation, drug allergy, radiation therapy, AIDS, hepatitis etc.

patients will be asked if he/she is having habit of smoking, chewing tobacco, areca nut etc.

dentist may ask you for about your parents, brother, sister are having any disease like diabetes, cardiac disorder, bleeding disorder, any genetic disorder, TB ( tuberculosis) .

Intra & Extra Oral Examination (IOE, EOE)

Dentist starts from extra oral examinations as head & neck, face & its structure, skin, swelling, eyes. any anomaly from normal is recorded in prescription in EOE segment.

e.g. swelling, sinus openings, concussion, laceration, skin tearing, nose/ear bleeding, burn, pallor etc.

In intra oral examination dentist do in two parts, soft tissues and hard tissues. soft tissues are like buccal mucosa (cheek from inside mouth), gingiva(gums), inside lips, tongue, below the tongue, pharynx, tonsils, etc. Teeth and bony part comes under hard tissues. Teeth will be examined as there is any caries or cavity, root stumps, severe decay of tooth, abrasion, attrition, tooth loss, impaction(submerged tooth), tooth mobility, pain on tapping or chewing, crowding( crooked teeth), retained milk tooth, fractured tooth, bony fracture etc,.

e.g. <caries i.r.t. 16> that means patient have infected tooth with cavity in upper right back tooth that is 1st molar.

There are few types of teeth numbering system which dentist use. like Universal system, FDI system(  Fédération Dentaire Internationale ), palmer notation system. there are some differences between these system even within a system one is for milk teeth and another is for permanent teeth. Here in this case 16 in denoting upper 1st molar which is came from FDI system.

IN FDI system all the 32 teeth are divided in 4 quadrants. 1st one is upper right from midline central incisor (of upper right side) to the last 3rd molar (of upper right side) , second is from left upper from central incisor to last molar, 3rd is lower left from midline to last molar, and 4th is lower right from central incisor to last/3rd molar. Tooth numbering is always starts from midline like 1st tooth from midline is 1 and if it is from 1st quadrant then will be written as 11 ( upper right central incisor) same as 18 will be upper right 3rd molar. 1st digit shows quadrant and second shows teeth number from the midline.

RESIDUE

Dentist may advice his/ her patient for radiographs, blood test, allergy test, blood sugar, blood pressure etc. on prescription. after getting all the details dentist will make correct diagnosis and will do start treatment. started or completely done treatment will also be written on the prescription. Now doctor will prescribe medicine on prescription on the basis of patient’s diagnosis. future recall or appointments may be given and could be written on the prescription.

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