Fundamentals of Treatment Planning. Lino Calvani
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