Fundamentals of Treatment Planning. Lino Calvani
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