Fundamentals of Treatment Planning. Lino Calvani
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.