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ОглавлениеData, findings, and dental semiotics
This topic is of paramount importance for diagnostic purposes. Certain terms and concepts are emphasized because they need to be crystal clear in the mind of all clinicians, whether they are experienced or still only novices. Sometimes, more experienced clinicians, in light of their experience, tend to simplify procedures to save time, and thereby fall into error.
Treatment planning is very important in prosthodontics. Data, findings, histories, signs, and symptoms are all necessary to any patient assessment as they work together to give us an overall picture of the patient’s health situation. The information we glean from their combination is vital to the planning of any treatment.1-7
Data and findings refer to the comprehensive collection of information necessary to arrive at the assessment of the patient’s current health situation such as:1-3,8
● histories (personal, medical, and dental);
● examinations (extraoral and intraoral);
● radiographs;
● other useful diagnostic aids.
Data refers to the information we obtain from taking patient histories. History taking is the first and main means of data gathering. Patient histories consist of all the information given by the patient, including both past and present information, and can be categorized as follows:9
1. The basic demographic information.
2. The chief complaint.
3. The medical history.
4. The dental history.
5. The prosthodontic history.
There are usually two ways of recording patient histories:
1. The initial questionnaires that patients fill out at the dental office before we meet and interview them (Fig 4-1).
2. The interview that we perform on meeting the patient, during which we start to communicate and interact directly with the patient. Through this spoken interaction, we deepen our observation and are better able to assess evident problems, dysfunctions, illnesses or diseases.10 This second opportunity may be performed using a second set of specialized questionnaires that serve to clarify and understand specific aspects of the patient’s health profile and serve to integrate further details into the initially gathered information to make it more comprehensive.
Fig 4-1 Example of a simplified format of an initial examination questionnaire.
Findings refer to the evident results obtained from both the hands-on clinical examination and further examinations such as radiographs and other diagnostic tools and aids used to investigate patients’ health and make a correct diagnosis. Generally, findings can be grouped into symptoms and signs that define any dysfunction, illness or disease.1-3
A useful way to think about the difference between a symptom and a sign is that patients feel the symptoms of their illness or disease and show the signs. As symptoms are subjectively perceived and described by each patient in a similar but different way, they may either be true or not true. Signs, on the other hand, are always true, as they are objectively perceived and are evident to the clinician, who will know them and recognize them as such. Signs are perceived by our senses and by the various diagnostic means at our disposal. They reveal their presence and characteristics without any doubt.
Symptoms are subjective – only patients feel them. Symptoms are the primary alarm bells of a dysfunction for a patient. They can be immediately referred to and described by a patient as the problem in the initial patient interview.1-3
Pure symptoms in dental medicine can be, for example:
● pain;
● discomfort;
● a rise in temperature;
● sensitivity to heat or cold;
● altered taste;
● numbness of the mouth or tongue.
Dysfunctions, illnesses or diseases rarely manifest as one symptom and are seldom diagnosed based on a single symptom. Usually, a symptom is associated with one or more other symptoms to characterize a specific health condition. We look at all the evident symptoms together during the initial questioning and subsequent clinical examinations to evaluate them as a whole in order to more precisely diagnose a patient’s problem.11
The qualities of symptoms – their duration, course, severity, and pattern of behavior (sudden, continuous, intermittent, episodic) – are described by patients using words such as light, heavy, terrible, worsening, improving, etc. These words, combined in various ways, guide us in assessing the origin of the symptoms and the reason for their manifestation.1-3 For example, a patient’s description of a mandibular third molar affected first by pericoronitis and then by a periodontal abscess may be: “It all started with episodic discomfort, with swelling behind the last tooth, which in a couple of days changed to a continuous dull pain. After a while, that worsened into terrible pain, and now I cannot even swallow or open my mouth. Even my ear is sore.”
Signs are objective. We use our senses to see or ‘read’ them on our patients. Just because patients may not feel a problem in their mouths does not mean the problem is nonexistent. Mostly, patients come to our offices without specific symptoms or complaints but for a routine check-up examination and/or a professional tooth cleaning. Sometimes, in these instances, we see a sign of a problem that patients have not even perceived, or if they have perceived it, have judged it to be unimportant because it is asymptomatic. Even diseases as serious as cancer are often not perceivable to the patient, and we notice them by chance due to the presence of a random sign.
We can say that signs are the secondary alarm bells of a dysfunction for a patient. They are the evidence of dysfunction that can be discovered and assessed during an examination. Signs may indicate a problem, as they are often visible. When they are not visible, it may be possible to touch or feel them (palpable), hear them (audible), or smell them. We can therefore say that in some way they are measureable. Signs can be directly measured (for instance, with a ruler) or indirectly measured (for instance, with a radiographic examination). Signs in dental medicine include:
1. Caries.
2. Plaque and calculus.
3. Pain on palpation or percussion.
4. Tenderness on palpation.
5. Swelling.
6. Redness.
7. Periodontal pocketing.
8. Bleeding on probing.
9. Measurement of probing depth.
10. Furcation involvement.
11. Root proximity.
12. Gingival abscess (pus).
13. Amalgam tattoo.
14. Oral mucosa lesions.
15. Bone loss.
16. Crepitus.
17. Malocclusions.
18. Wear facets.
19. Widening of periodontal ligament.
20. Open margin of a fixed prosthesis.
21. Oral cancer (visible lesions).
Simultaneous symptoms and signs
A simultaneous association of a number of symptoms and signs is also possible. These so-called symptom-signs perceived and reported by the patient and perceived and observed by the clinician could be:
1. Bad breath (clinician and patient both smell it).
2. Dry mouth or xerostomia (patient feels it, clinician sees it).
3. Dysphagia (patient feels it, clinician sees it).
4. Bleeding.
5. Inability to speak properly.
6. Speech changes.
7. Loss of ability to chew.
8. Esthetic problems.
9. Tooth mobility.
10. Tooth fracture.
11. Tooth loss.
12. Fever or hyperthermia (measurable).
13. Altered skin color.
14. Skin moisture content.
15. Cancer.
16. Tooth sensitivity.
17. Reaction to pulp tests such as cold, heat, a low dosage of electricity (felt by the patient as a symptom, induced and seen by the clinician as a sign).
Main symptoms and signs in dental medicine
Pain is the main and most important symptom and is usually the patient’s chief complaint. Closely related to pain is discomfort, which is second only to pain in terms of intensity or sensitivity. The two are directly related and should be considered together. Other important symptoms and signs (so-called ‘ringing bells’) that should be taken into account during any patient evaluation are inflammation, xerostomia, dysphagia, fever, and hyperthermia. These main signs and symptoms are indicative of an existing problem and need to be investigated in terms of their severity, duration, and location in order to make a precise diagnosis. They may vary according to changes in the patient’s posture, temperature, or activity (ie, whether the patient is at rest or chewing).1,12
Pain
Dental pain may be caused by a wide variety of problems such as acute pulpitis, dental abscesses, fractured teeth, acute pericoronitis, myofascial dysfunctions, etc. It is important to delve a bit deeper into the origin of the pain. The definition of pain in the Glossary of Prosthodontic Terms states: “Pain n (13c): a subjective unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage — see acute pain, chronic pain, heterotopic pain, masticatory pain, musculoskeletal pain, myogenous pain, neurogenous pain, odontogenous pain, primary pain, projected pain, secondary pain, vascular pain, visceral pain.”13-15
Pain is a complex phenomenon. It is the natural alert for patients of a possible ongoing problem that the clinician cannot see, as there is no evidence of it apart from the patient’s subjective description.16-18 As mentioned previously, pain is always relative to the individual patient, as everyone perceives it differently and describes and evaluates it in a unique way.16,19,20
Some patients suffer from clinical conditions where they are unable to perceive pain at all (analgesia). An example of such a condition, hereditary sensory and autonomic neuropathies (HSAN), is a disorder characterized by the malfunctioning or nonfunctioning of pain receptors.13,19,21-23 The classic and most dangerous example of this disorder is type IV HSAN, called HSAN IV. It is also known as congenital insensitivity to pain with anhidrosis (CIPA) or Nishida syndrome.23,24, This disorder has two characteristic features: the incapacity to feel pain and temperature, and the decrease in the ability or the inability to sweat (anhydrosis). These inabilities can lead to repeated injuries that may become debilitating such as biting the tongue, lips, cheeks, or fingers. In some extreme cases they can be dangerous, leading to severe wounds and in rare instances to the necessity to amputate the affected area. Other serious conditions such as hypertension and diabetes may cause hypoalgesia; therefore, they need to be investigated and assessed before any oral treatment.
Furthermore, drugs may reduce a patient’s capacity to feel pain by inducing a decreased sensitivity to painful stimuli (hypoalgesia). When medications affecting the sensory system are taken or abused – such as analgesics (eg, carbamazepine) or nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, aspirin, ibuprofen, naproxen, and paracetamol) – they may affect a patient’s ability to sense pain and perceive damage in the oral cavity.23,25,26 Opioids, currently widely used not only in the USA but increasingly worldwide, may heavily reduce pain perception. This increases the possibility of patients hurting themselves when chewing, speaking or during certain parafunctions.
We also need to bear in mind that sometimes patients’ pain may be psychologic in nature, ie, the pain may not be actual or real, but rather imagined. This is a complex topic and relates to patients’ present or past negative experiences, expectations, fears, anxieties, and traumas.19-21,27-31 It could be that the patient is describing as pain something that is actually discomfort.31,32 If reported pain is associated with tissue damage, clinical evidence will prove it. It is important for us to be attentive and sensitive in our clinical examination of patients in order to verify whether pain actually exists and whether it is truly related to damage or disease in the oral cavity.21,30,33
Anxious patients are often more likely to report pain and discomfort for reasons such as their overestimation of danger, conditioning past perceptions and experiences, hypersensitivity to cold and heat, emotional expectations, loss or lack of control, muscle tension or rigidity, cultural and educational attitude, etc.19,20,28 When assessing the cause of any pain in a clinical examination, it is advisable to correlate reported pain with the level of anxiety in the patient and to consider possible related psychologic signs and symptoms. In this way, we can better assess whether the pain is due to real damage, dysfunction or disease, and whether it relates to a real sensory experience or is due to emotional trauma or worry.21
There may be many causes of a patient’s pain (see the definition of pain and its many subsidiary categories in the Glossary of Prosthodontic Terms, on page 37). Each one may have different origins and characteristics such as:
1. Pain location (localized, diffused, and/or migrating).
2. Association with other symptoms or evident signs.
3. Specific characteristics (insurgence, quality, duration, intensity).
4. Existing aggravating factors (function, temperature, head posture, stress, medications).
5. Possible relationship with other concomitant ailments or previous problems.
It is important to be aware of all these clinical possibilities. In general, we should not under- or overestimate the importance of these symptoms as they form the basis of the decisions we make in terms of the diagnosis and treatment plan.12,18
Inflammation
Inflammation or phlogosis (from the Greek phlogos meaning ‘flame’ – which refers to the burning sensation that is one symptom of inflammation) is the first natural defense response of any living tissue to an injury. It is the cause of symptoms and signs such as swelling, discomfort, redness, pain, burning, and fever.
Inflammation is not purely a local event but often actively involves the entire body. It is a set of cyclic modifications, called inflammatory process moments, that occur at the vascular-connective tissue level when the body reacts to harmful agents. These agents can be of a differing nature and origin and usually cause a gradual rather than immediate and complete destruction of tissue.34,35
Furthermore, inflammation is a pathologic event that needs the vitality of the tissues as well as excellent blood and lymphatic vessel functionality. It also needs the necessary means to convey the defense inflammatory components locally and spread them throughout the entire body.35,
Inflammation may be caused by a variety of agents such as:
1. Physical: mechanical, thermal, electrical or actinic injuries, foreign bodies, inert materials, etc.37
2. Chemical: poisons (ingestion or injection), abnormal metabolic products, blood levels, etc.37
3. Biologic: presence of antigen-antibody complexes, hydrolytic enzymes, plasmatic quinines, a small amount of activated complement, etc.38
4. Infectious: presence or invasion of viruses, bacterial microorganisms, bacterial endo- and exotoxins, protozoa, fungi, parasites, macro-organisms, etc.39-42
Other factors that affect the inflammatory reaction process are age, nutritional deficiencies, severe metabolic diseases, immune capabilities, and the amount of hormones in the body such as cortisone, hydrocortisone, corticosteroids, etc.35,43-45
Inflammation processes can be peracute, acute, subacute or chronic. They usually require a medical response and can last for a long period of time.35,46
Aulus Cornelius Celsus, the Roman encyclopedist (25BC to 50AD) in his book De Medicina, was the first person to highlight the four local signs of inflammation:
1. Rubor (redness).
2. Tumor (swelling).
3. Calor (heat).
4. Dolor (pain).
There is also a fifth macroscopic sign of inflammation, which is functio laesa (loss or disturbance of function). This was identified by Galen, who later added it to the four signs identified by Celsus. Actually, the attribution to Galen is disputed, and has variously been attributed to Thomas Sydenham and Rudolf Virchow. Nevertheless, whoever was responsible for identifying it, function laesa is a clinical reality,47,48 in light of which the original four signs of inflammation can be amended to the following five:
1. Redness (rubor): acute hyperemia of the inflamed tissue.
2. Swelling (tumor): edema of fluids and inflammatory cells in the extravascular inflamed area.
3. Heat (calor): local higher temperature due to hyperemia and the vascular dilation local reaction effect.
4. Pain (dolor): due to acute inflammation chemical mediators such as some prostaglandins as well as bradykinins. It can also be due to the swollen and deformed tissue.
5. Loss of function (functio laesa): the macroscopic reduction or lack of functionality of the inflamed area that may be due to pain and the stiffness that results from swelling.
According to general pathology doctrines, the clinical expressions of inflammation consist of:
1. Circulatory alterations: the permeability of vessels, local plasmatic exudation, and edema.
2. Corpuscolated exudation: blood cells, connective local and mobile cells.
3. Regressive phenomena: anatomical and functional alterations, including necrosis.
4. Regenerative phenomena: substitution damaged cells, new original reparatory tissue, or various types of scar tissue.
Inflammation can have beneficial and detrimental effects, both locally and systemically. It is an extremely important sign in dental medicine and is therefore touched on later in the book (see Chapters 7, 8, and 10).
Xerostomia and dry mouth
Xerostomia is both a symptom and a sign. It is both a subjective sensation of dry mouth as well as the evident reduction or lack of saliva. It affects almost 20% of elderly patients. Xerostomia is one of the most significant problems in the oral cavity because the lack of saliva may dramatically increase the frequency of caries, the rate of infections due to candida, the onset of dysphagia (difficulty swallowing), and the onset of dysarthria (difficulty articulating phonemes and words).49-51 It is potentially a serious problem that may cause the onset of other clinical problems.49,52,63
There are several different causes of xerostomia:
1. Iatrogenic causes such as medications, chemotherapy, local radiation therapy, chronic graft-versus-host disease (GVHD) due to the transplantation of allogenic stem cells.52,53,99
2. Salivary gland diseases such as Sjogren’s syndrome, diabetes mellitus, hepatitis C, sarcoidosis, HIV, biliary cirrhosis, cystic fibrosis.54-58
3. Other causes such as inadequate intake of food, hemochromatosis, amyloidosis, salivary gland agenesis, Wegener’s disease, triple-A syndrome.49,59,60
4. Drugs: This is a major cause of xerostomia. As drugs are often responsible for xerostomia, clinicians should ensure that they know exactly what medications patients are taking and which of these could possibly cause dry mouth.61-63 This is one of the reasons why it is crucial to collect comprehensive medical and dental drug data during the first diagnostic phase.
To date, there are 25 categories of medications representing some 133 generic drug names that have xerostomia as a side effect, as follows:
1. Anorexiant.
2. Antiacne.
3. Antianxiety.
4. Antiarthritic.
5. Anticholinergic/antispasmodic.
6. Anticonvulsant.
7. Antidepressant.
8. Antidiarrheal.
9. Antihistamine.
10. Antihypertensive.
11. Anti-inflammatory/analgesic.
12. Antinauseant.
13. Antiparkinsonian.
14. Antipsychotic.
15. Antisecretory.
16. Antispasmodic.
17. Antiviral.
18. Bronchodilator.
19. CNS stimulant.
20. Decongestant.
21. Diuretic.
22. Migraine.
23. Muscle relaxant.
24. Narcolepsy, narcotic, analgesic.
25. Ophthalmic sedative.
Composite drug therapies can cause xerostomia. It is common for patients to take several drugs simultaneously for various problems, and their interaction may exacerbate dry mouth. Therefore, during the initial diagnostic phase, it is important that we scrutinize the patient’s answers to the questionnaires and investigate a bit deeper in our interview with the patient to ensure that we are aware of all the drugs the patient is taking. We also need to have a sound knowledge of their effects, side effects, and interaction with each other to properly diagnose and treat our patients and avoid future unexpected surprises or possible misunderstandings.63
Dysgeusia and taste impairment
This important symptom is often underestimated and especially affects elderly patients. Taste, or gustatory perception, is a natural warning system that developed through evolution so that, apart from tasting when food or drink is good, humans are able to detect when it is spoiled and may endanger their health and life. This includes the ability to detect substances to which we may be allergic. Taste receptors are located on the tongue as well as on the roof, sides, and back of the mouth, on the epiglottis, and in the throat.32,64,65
Dysgeusia is a condition in which a foul, salty, rancid or metallic taste sensation appears and remains in the mouth. Sometimes, patients report that this symptom started with the delivery of a prosthetic device or some other metal object in their mouths. Patients may attempt to place the responsibility for the symptom on the prosthodontist/s who planned and delivered the restoration. We need to investigate the cause of the dysgeusia carefully because sometimes it is caused by something other than the restoration, in which case we need to explain this in a gentle and kind way to the patient. The U.S. Department of Health and Human Services – National Institutes of Health reports that in the USA some 200,000 people visit a doctor each year for problems with their chemical senses, which includes taste and smell. This significant number of patients, which in fact may be just the tip of the iceberg, means that many people experience problems with these two senses. It is therefore usually too simplistic to relate the symptom of dysgeusia to a purely prosthodontic cause. Furthermore, taste and smell are closely related, and it is sometimes confusing in certain conditions to tell whether a patient has a taste or a smell disorder.66-69
Taste as a risk factor
Taste disorders may create serious health problems as they can be a risk factor for stroke, diabetes, heart disease, and other conditions where a careful diet must be followed. Impaired taste may cause patients to dramatically limit their food intake so that they experience massive weight loss, with the teeth having nothing to do with it.70,71 This situation may also cause depression. This is important to know and remember in the initial diagnostic phase.
Possible causes of dysgeusia and altered taste disorders are:
1. Drug use or abuse.
2. Poor oral hygiene.
3. Third molar extraction surgeries.
4. Upper respiratory tract and middle ear infections and surgeries.
5. Head injuries.
6. Radiation therapy for head and neck cancer.
7. Exposure to chemicals such as insecticides.
8. Central nerve system pathologies.
When loss of taste is a chief complaint that cannot be related to a disease in the oral cavity, we should advise the patient to consult a physician, as this symptom may be a precursor sign (together with an impairment of the sense of smell) of a severe nervous system pathology such as Parkinson’s disease or Alzheimer’s disease.72,73
Drugs that may affect taste
When a patient reports an altered, reduced or absent ability to taste as a chief complaint, we need to ensure that we see and understand the full clinical picture. As described in the previous section regarding dry mouth, an affected sense of taste may be due to drugs the patient is taking. It is therefore important to know exactly what these are, so that if patients claim to have an affected sense of taste due to a prosthesis or other dental work in their mouths, we can explain to them that it may be due to the drugs they are taking.74
There are 46 categories of medications representing some 151 generic drug names that can cause an altered or lost sense of taste as a side effect, these being:
1. Alcohol detoxification medications.
2. Alzheimer’s disease medications.
3. Analgesics (NSAIDs).
4. Anesthetics (general and local).
5. Anorexiants.
6. Antacids.
7. Antiarthritics.
8. Anticholinergics.
9. Anticonvulsants.
10. Antidepressants.
11. Antidiabetics.
12. Antidiarrheals.
13. Antiemetics.
14. Antifungals.
15. Antigouts.
16. Antihistamines (H1) antagonists.
17. Antihistamines (H2) antagonists.
18. Antihyperlipidemics.
19. Anti-infectives.
20. Anti-inflammatories/anti-arthritics.
21. Antiparkinsonian.
22. Antipsychotics.
23. Antithyroid.
24. Antivirals.
25. Anxiolytics/sedatives.
26. Asthma preventives.
27. Bronchodilators.
28. Calcium-affecting drugs.
29. Cancer chemotherapeutics.
30. Cardiovascular drugs.
31. Central nervous system stimulants.
32. Decongestants.
33. Diuretics.
34. Glucocorticoids.
35. Gallstone drugs.
36. Solubilization medications.
37. Hemorheological medications.
38. Immunomodulators.
39. Immunosuppressants.
40. Methylxanthines.
41. Nicotine cessation drugs.
42. Ophthalmics.
43. Systemic retinoids.
44. Salivary stimulants.
45. Skeletal muscle relaxants.
46. Vitamins.
Fever and hyperthermia
Fever and hyperthermia, which are also signs and symptoms in dental medicine,75 have different causes and should therefore be carefully investigated in order to make a proper differential diagnosis.76
Hyperthermia is an increase of body temperature beyond 100.4°F (38°C) due to either an external heat increase in the environment or internal sources such as excessive intake of hot beverages; physical muscle activity; hyperthyroidism; use of drugs such as interferons; excessive use of drugs such as atropines, antiepileptic drugs, and phenothiazines; or due to intoxications caused by aspirin, antibiotics or carbon monoxide. These aspects need to be identified during the examination if we are faced with an unclear increase in a patient’s body temperature.77-79
Fever, on the other hand, is an increase in body temperature beyond 98.6°F (37°C). This clinical sign is a very important indicator of a possible disease or condition that needs to be identified and healed.80 The presence of fever means two things: one negative and one positive. First, it indicates that the body is reacting to a pathogen, which is a negative sign and a warning of a present invasive problem. Second, it indicates that the body is reacting to such a pathogen, which is a positive sign because it indicates that the host’s defense system is functioning healthily.
Fever induces an overall increase in lymphocyte activity, leucocytes migration, phagocytosis, natural interferon production, and plasmatic iron.81 It must be assessed to understand its causes. Furthermore, although it needs to be respected, we should not try to eliminate it completely as it is an important signal of something being wrong; instead, we should try to lower it, and then only if it creates discomfort for the patient.
Fever caused by ear, nose (sinusitis), and other oropharyngeal infections often occurs and may be confused with fever caused by dental or periodontal problems.
Fever in dental patients may mean an infection somewhere, and its origin may indeed be found in the mouth. However, even if this is the case, it may not necessarily be due to a localized dental or periodontal problem, but rather to a bacterial infection that originated intraorally and afterwards created infective foci elsewhere in the body. An example of this is infective endocarditis (IE), which is ‘silent’ until the disease is evident.82 Many oral microbiota are responsible for IE and many other infections, the main symptom of which may be even a slight fever. They are all associated with the most common routine activities such as toothbrushing, flossing, and chewing. Therefore, during the chairside physical examination, we need to make a differential diagnosis between an occurring general infection, an oropharyngeal infection, a dental infection, and the side effect of a drug. The collection of patients’ data and findings is fundamental to ascertain how all these aspects are related.
Both young and elderly patients are particularly vulnerable to fever as their immune systems are either not fully developed or becoming deficient. Moreover, prosthodontic patients are often elderly.75,83-86
In case of a fever, detecting the source of infection is fundamental during the physical head and neck examination and diagnosis, as many viral and bacterial infections begin in the oral cavity; therefore, the oral cavity should be the first point of treatment to control the pathogens and prevent their spread.82,87
Consultation with the patient’s physician may be necessary to determine susceptibility to bacteria-induced infections (such as IE), and specific antibiotics are recommended for all dental procedures involving manipulation of the gingival tissue or the periapical region of teeth in this type of patient.
Therefore, behind the simple symptom or sign of even a slight fever there might be a number of causes that need to be assessed to arrive at a correct diagnosis.
Semiotics and dental semiotics
The word semiotics derives from the Greek sēmeiōtikos meaning ‘observance of signs’, from sēmeion, which means ‘sign or mark’. The word was originally used prior to 1676 by Henry Stubbes to define that branch of medical science that studies the interpretation of body signs.88
Humans (like all animals) naturally relate to the environment through the five senses of sight, touch, hearing, smell, and taste. We do this for two main reasons: food and reproduction.89 Since humans have the capacity for intellect (consciousness), their senses are not as highly developed as in other animals. Despite this, our five senses still serve the survival purpose for which they were intended.90
The sense of taste was once used in medicine to establish the characteristics of certain secretions and excretions. For instance, in 1675 the British physician, Thomas Willis, coined the name ‘diabetes mellitus’ (mellitus is Latin for honey) because he made his diagnosis by tasting the patients’ urine, which in the case of this disease is sweet. Obviously and fortunately, this is no longer the way we test for the presence of this disease clinically and in the modern laboratory!
Since we are aware that we already naturally use our senses, we must become experts at using them when meeting and examining our patients and collecting clinical information. It follows that it has become a natural process to observe and study the best way to use our senses when performing patient examinations.4,6,91 The diagnostic action of using our senses has been formally defined by semeiotic medical science and is useful when combining signs and symptoms to assess the chief complaint and other medical problems of which, at times, even the patients themselves are unaware. As professionals, we must be well trained in the science of semiotics because those who are highly capable in this science are ultimately better clinicians. Clinicians who have been practicing for a long time develop, through experience, the most sensitive and perfected semiotic skills.92
Medical examinations should follow a particular sequence that is well known: inspection, palpation, percussion, auscultation, and olfaction – IPPAO.4,6,7,88 These five clinical examinations are discussed below.
Inspection or examination by viewing
Inspection is the gathering of visual evidence.6,93,94 A number of factors should be borne in mind and the following sequence followed when inspecting a patient:
1. Examine the patient in sufficient light (preferably natural light) so that colors are as true as possible.
2. Examine the patient in a well-defined standing, seated or lying down position.
3. Examine the anatomic area and the area surrounding it without anything covering these areas.
4. Note not only the possible pathologies but also their absence.
5. Analyze all possible pathologies in terms of:
a. Morphologic changes such as location, shape, volume, borders, surface, color, etc.
b. Functional changes such as physiologic, spontaneous, and uncontrolled movements such as tremors, tics, muscle contractions, etc.
c. Morphologic characteristics of the surrounding areas and tissues.
6. Pay attention to the patient’s facial expression.
7. Pay attention to the patient’s body posture.
8. Pay attention to the patient’s attitude.
9. Determine whether the patient is attentive, absentminded or has diminished eyesight.
10. Pay attention to the mode and quality of the patient’s speech.
11. Note any possible facial symmetries and/or asymmetries.
12. Note the facial mobility.
13. Note the color of the face; its pallor, possible cyanosis and/or other colors.
14. Note the head and neck posture.
15. Note the jugular venous pressure (JVP) or the rhythmic pressure of the external carotid arteries.
16. Note any possible lymph node swellings or other lumps and/or deformities.
17. Examine the masticatory muscles (normal, ipotrophic or ipertrophic).
18. Note any slack, trembling or parafunctional mandibular movements.
19. If visible, note the form, dimensions, and color of the tongue and any unnatural tongue movements.
20. Note the hands and finger movements.
Further detail is provided in Chapter 7.
Palpation or examination by touching
This involves using the 2nd, 3rd, and 4th fingers (in some cases only the fingertips when we need to reach certain narrow areas such as the pterygoid muscles in the retrozygomatic fossa) to gently touch or press the tissues as we perform a head and neck examination. We can also use the palms of our hands for larger body surfaces.8,95 If we detect any nodules or swellings in this way, we should check their location, temperature, shape, consistency, volume, borders, and surface texture. We should also note whether they move spontaneously (physiologic or pathologic mobility), whether they are reducible, whether they are pulsating, and their position in relation to the surrounding tissue and regions.
We should also palpate over the three bilateral emergencies of the fifth trigeminal nerve, or over the seventh facial nerve. The latter, having different sensory and motor branches, needs a more specific examination (described in Chapter 7).
Be sure to note if any discomfort, tenderness or pain is experienced by the patient after the palpation examination.
In dental medicine and prosthodontics, the use of instruments such as explorers and probes may help to detect open margins, caries, cracked teeth, calculus, pocketing, and inflammation. These instruments may be included in this tactile examination.
Touch allows us to palpate the borders of the peripheral seal of a complete denture to verify the existence of roughness and/or acute angles that are deleterious for the patient’s oral mucosa.
Percussion or examination by tapping
In 1761, Auenbrugger described this method, and with the passage of time it has been further perfected. In medicine, percussion refers to tapping over several concave parts of the body such as the chest, shoulders, and abdomen to elicit sound information that may help to establish the position of the organs. It also allows us to determine whether any organs or parts of them have pathological changes of density, consistency, and/or air content. In dental medicine, tapping over a tooth may elicit pain or sensitivity symptoms that inform us of a masked or partially hidden ongoing periapical problem.96 Also, tapping over an implant may give a positive or negative indication regarding its integration, or it may indicate the presence of a possible fracture.
Auscultation or examination by listening
Laennec introduced this method in 1819. In dental medicine, listening to the normal or altered speech and phonetics of patients while trying-in a new restoration is usually performed using the ears only, without the aid of instruments such as stethoscopes. An analog or digital stethoscope can be used when we need to amplify temporomandibular joint (TMJ) murmurs, clicks, crepitus, and other sounds that guide us in making a temporomandibular disorder (TMD) diagnosis.97 Listening without a stethoscope is also used for maxillofacial prosthetics, where it is important to listen for speech defects, and in prosthodontics, where, for instance, complete denture prosthetic teeth mounted at an excessive increased vertical dimension may result in the sound of the teeth making immediate occlusal contact as well as other related tooth sounds when the patient is speaking.
Olfaction or examination by smelling
Smelling also allows us to detect both physiologic and pathologic information that can assist us to make a correct diagnosis. This examination is useful to indicate, for instance, the immediate evidence of alcohol or tobacco use by the patient. A sweet or fruity acetone smell could be an indication of ketoacidosis, a serious complication of diabetes that occurs when the body produces high levels of ketones. A similar odor can be perceived if a patient is on a strict diet or has been fasting. An unpleasant smell is also evident in the case of acute necrotizing ulcerative gingivitis (ANUG), a common non-contagious infection of the gums, or in case of ulcerations present in the oral cavity due to the presence of blood, or in the case of gastroesophageal reflux disease (GERD), with its strong acid aroma. Other conditions that we can smell on the patient are urine incontinence and the odor of melaena, the production of feces containing partly digested blood that results from internal bleeding or the swallowing of blood. These and a number of other sometimes barely perceivable smells help us to detect findings that can assist us to develop an accurate general clinical picture and to arrive at a correct diagnosis.98,99
Therefore, by examining patients using our five senses, we perceive signs and symptoms that give us vital information. Our experience allows us to combine, assess, and integrate that information toward a more thorough understanding of the problems afflicting our patients so as to make a correct diagnosis and a predictable prognosis.
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