Many years ago, Dr Arthur Elfenbaum, a professor of oral diagnosis and oral medicine in Chicago, wrote a regular monthly column in a digest-sized publication called Oral Hygiene. One of the memorable articles was entitled “The Patient at the Consulting Room Door.” Among the issues he covered in this sage presentation was the importance of evaluating the entire patient, including gait, skin color, posture, and speech.
The good doctor was telling his readers to look outside the box. A patient seeking dental care represented more than a mouth with missing, carious, or periodontally involved teeth. His or her emotional, mental, and physical status should play a major role in treatment planning. Dr Elfenbaum advised that the gait could reveal histories or the presence of rickets, rheumatoid arthritis, tabes dorsales, or birth defects; that the skin, scleral, or labial color might indicate congestive heart failure, jaundice, hepatic disease, polycythemia vera, or severe anemia; and that the eyes might reveal a cirrhotic liver. Slurred, ill-defined speech or hoarseness might direct you to consider whether the patient has had a cerebrovascular accident, laryngeal polyps, a malignancy, or a mental aberration. A purplish, enlarged, and venously invaded nose (rhinophyma) indicates a possibility of alcoholism; bulging eyes (exophthalmos) might mean hyperthyroidism or the remote chance of Hand-Schüller-Christian disease or hyperparathyroidism.
Dr Elfenbaum strongly urged that the initial interview be conducted in a relaxing environment such as your consulting room, not in a threatening arena like an operatory. After the patient is comfortably seated, you will have the opportunity to listen to his or her breathing. Here, it becomes possible for you to detect the stertorous sounds of emphysema or other respiratory disease.
If you are able to see the patient's hands, additional information like bluish nail beds or clubbed fingers might offer a hint about congestive heart failure. No matter how busy you are, these observations and the subsequent recording of the patient's complaints, medical history, and the reasons for the visit are best recorded by you rather than a staff member. In this manner, you may be able to assess the patient's level of intelligence, comprehension, education, and priorities. It is to your advantage to listen and observe rather than to interrupt or pontificate. Your time to speak will come after you have assessed the individual facing you and have written down the responses to your careful questions directed toward the patient's knowledge, needs, and goals; the patient's physical and mental symptoms; and your observations using Dr Elfenbaum's previously cited diagnostic tools. Then, and only then, should you accompany the patient into an operatory where the physical exam is to be conducted. Remember that your entire course of treatment, though theoretically sound, may succeed or fail based on your levels of acuity in the initial visit.
The American Society for Geriatric Dentistry sponsors an Annual Essay Award Contest named in honor of Dr Arthur Elfenbaum, who devoted much of his professional career to geriatric issues. It was established in 1985 and is available to US and Canadian students (of dental and dental hygiene). It is a fitting tribute to a doctor who wrote so well to advocate for the best possible diagnostic procedures for all patients.
A. Norman Cranin, DDS, DEng, is Editor-in-Chief of the Journal of Oral Implantology