“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone canyou become an expert.”
Sir William Osler
Diagnosis is the bridge between the study of disease and the treatment of illness. Making a distinction between disease and illness appears redundant because the words frequently are used interchangeably. However, diseases of the oral cavity and related structures may have profound physical and emotional effects on a patient, and a holistic approach to patient care makes this distinction significant. In oral pathology one studies disease; in clinical dentistry one treats illness. For example, necrotizing ulcerative gingivitis may be defined with special emphasis on the microbiological aspects of the disease, or one may speak of an inflammatory reaction featuring “punched-out” erosions of the inter dental papillae. However, necrotizing ulcerative gingivitis is more complex. It is the totality of symptoms (subjective feelings) and signs (objective findings) that together characterize a single patient’s reaction-not merely a tissue response-to infection by spirochetes. While disease is an abstraction, illness is a process.
Similarly, clinicians must recognize that systemic disease may affect the oral health of patients and to treat dental disease as anentity in itself is to practice a rigid pseudoscience that is more comforting to the clinician than to the patient. The diagnosis and treatment of advanced carious lesions afford little support to the patient if one over looks obvious physical findings suggesting that the extensive restorative needs were precipitated by qualitative and quantitative changes in the flow of saliva secondary to an undiagnosed or uncontrolled systemic problem, or anticholinergic pharmacotherapy. The clinician with a balanced view of dentistry will recognizethat caries is only a sign of disease and preventive and therapeutic strategies will have to be based on many patient-specific factors.
It is axiomatic that while dentists are the recognized experts on oral health, they must also learn of systemic diseases. Such an obligationis tempered only by the extent towhich systemic diseases relate to the dental profession’s anatomic field of responsibility,the extent to which illnesses require modification of dental therapy or alter prognoses, and the extent to which the presence of certain conditions (infectious diseases) may affect care givers. Consequently, clinicians should not treat oral diseases as isolated entities. They should recall that physical signsand symptoms are produced by physical causes. Since physical problems are the determinants of physical signs and symptoms, these signs and symptoms must be recognized before the physical problems can be diagnosed and treated.
It is through the clinical process that clinical judgment is applied and, with experience, matures. Clinical judgment does not comeearly or easily to most clinicians. It is forged from long hours of clinical experience and a life-long commitment to the disciplined studyof diseases and illnesses. Clinician’s should study books to understand disease, studypatients to learn of human nature and illness, and model mentors to develop clinical judgment. Ultimately, the experienced clinician will merge the science of understanding disease and the art of managing illness. These activities should be fostered by the clinician’s sincere desire to minimize patient discomfort, both physical and emotional, and to maximize the opportunities to provide optimal care.