|Year : 2019 | Volume
| Issue : 3 | Page : 257-262
Clinical and radiological signs of importance for the oral physician and oral surgeon
Abhay S Kulkarni, Rajendra S Birangane, Pratik C Parkarwar, Abdullah Zakaria Kazi
Department of Oral Medicine and Radiology, P. D. U. Dental College and Hospital, Solapur, Maharashtra, India
|Date of Submission||26-Apr-2018|
|Date of Acceptance||09-Nov-2018|
|Date of Web Publication||30-Sep-2019|
Dr. Abdullah Zakaria Kazi
Department of Oral Medicine and Radiology, P. D. U. Dental College and Hospital, Solapur, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Diagnosis of any disease depends on careful observation and documentation of signs. The careful observation of signs is important for diagnosis of diseases. Almost all major diseases and syndromes have some or other forms of oral manifestations, and many a times these are the first signs and symptoms of the disease or condition. The oral physician is at an advantageous position to detect these changes and diagnose the condition at the earliest, thus improving the overall standard of patient care. Most of the signs give the impression since beginning and some have to be provoked by the examiners. The objective of this review is to highlight the signs manifesting in orofacial area clinically and radiologically and increasing the awareness and knowledge of these entities for use in clinical practice.
Keywords: Clinical signs, pathognomonic signs, radiological signs, signs
|How to cite this article:|
Kulkarni AS, Birangane RS, Parkarwar PC, Kazi AZ. Clinical and radiological signs of importance for the oral physician and oral surgeon. J Indian Acad Oral Med Radiol 2019;31:257-62
|How to cite this URL:|
Kulkarni AS, Birangane RS, Parkarwar PC, Kazi AZ. Clinical and radiological signs of importance for the oral physician and oral surgeon. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Dec 13];31:257-62. Available from: http://www.jiaomr.in/text.asp?2019/31/3/257/268277
| Introduction|| |
The word sign refers to an important physical finding or observation made by the physician when examining the patient. This is a phenomenon that is often detected by the person other than patient. Every disease will represent in the form of signs and symptoms. Most of the signs are common for all diseases, but few signs can be pathognomic for a particular disease. These signs can be detected clinically, radiologically or on laboratory test. The objective of this review is to highlight the signs manifesting in orofacial region and manifesting in the other parts of body which are important for the oral physician. The entities included in this review will definitely suggest the oral physician and/or the general dentist a diagnostic clue of the disease.
A number of definitions are given by various authors for sign:
Oxford Dictionary defines it as an indication of a disease detectable by a medical practitioner even if not apparent to the patient.
Webster's New World Medical Dictionary defines it as any objective evidence of disease, as opposed to a symptom, which is, by nature, subjective. For instance, presences of frank blood in stool is a sign; this can be recognized by the patient, physician, or someone else as opposed to abdominal pain which is a symptom, which only the patient can notice.
Following are some of the variants of signs
- Anamnestic signs (from anamnēstikós, “able to recall to mind”): signs that indicate the past existence of a certain disease or condition, taking into account the current state of a patient's body. These signs point to the past. For instance, skin scars may be evidence of severe acne in the patient's past. Bone scar orosteosclerosis is seen in case of condensing osteitis even after the extraction of the offending tooth on radiographs
- Cardinal signs: A cardinal sign is the primary or major clinical sign or signs by which a diagnosis is made. E.g., inflammation is characterized by five cardinal signs. Four cardinal signs of TMJ Disorders, i.e., pain in TMJ and muscles of mastication; TMJ sounds; tenderness of TMJ and muscles of mastication and lastly TMJ dysfunction 
- Clinical signs: The abnormalities of structure or function observed in the patient by the clinician in a clinic or bedside examination. These are customarily graded according to severity, e.g., severe, moderate, mild, and according to its onset and progression, e.g., acute, subacute, chronic, and intermittent. Clinical signs such as rash and muscle tremors are objectively observable both by the patient and by anyone else. E.g., Clinical sign of carcinoma of maxillary sinus is a recently acquired malocclusion or displacement of maxillary teeth and vertical mobility (teeth undermined by the neoplasm)
- Diagnostic signs (from diagnōstikós, “able to distinguish”): Signs that lead to the recognition and identification of a disease (i.e., they indicate the name of the disease) For example, elevated levels of PSA (prostate-specific antigen) in a male patient's blood may be a sign of prostate cancer or a prostate problem. Similarly, tenderness on vertical percussion of a tooth will be a diagnostic sign that the inflammatory process has reached the periapical region
- Elicited Signs: Some signs belong only to the physical examination, because it takes medical expertise to elicit or unmask them. E.g., Nikolsky's sign
- Histopathological signs: Histopathological sign refers to the signs observed during microscopic examination of tissue in order to study the manifestations of disease. E.g., Flag Sign in actinic keratosis
- Medical signs: A medical sign is an objective feature indicating a medical fact or characteristic that is detected by a physician, nurse, or medical/laboratory device during the examination of a patient. Clubbing of the fingers-this may be a sign of lung disease. Pale oral mucosae will be a sign of anemia
- Ominous Sign: Ominous means an indication that something unpleasant is likely to happen or something threateningly inauspicious is about to happen. Thus ominous sign is an indication of poorer prognosis of the particular condition. Trismus is an ominous or dreaded sign in oral cancers affecting retromolar triangle or the retromolar pad. It indicates extension into the masticator space and pterygoid region possibly indicating the skull base extension 
- Pathognomonic signs (from pathognomonikós, “skilled in diagnosis”, derived from páthos, “suffering, disease”, and gnṓmon, “judge, indicator”): The particular signs whose presence means, beyond any doubt, that a particular disease is present. They represent a marked intensification of a diagnostic sign. The pathognomonic sign is the “clincher”, the datum that established the diagnosis unequivocally. Example: Target or Iris lesions are pathognomonic sign of Erythema multiforme 
- Prognostic signs (from progignṓskein, “to know beforehand”): Signs that indicate the outcome of the current bodily state of the patient (i.e., rather than indicating the name of the disease)., They predict the outcome for the patient-what is likely going to happen to them. E.g., Total tumor volume (TTV) is measured by computed tomography (CT) scan, in an important prognostic indicator in head and neck neoplasms. TTV of less than 6 cm 3 had better local control over tumor progression
- Prodromal signs: Prodrome is an early sign or symptom. It is derived from Greek word prodrome meaning running before, which often indicate the onset of a disease before more diagnostically specific signs and symptoms developed. Prodromal may present as vague symptoms or, sometimes, may undoubtedly specify a particular disease, such as the prodromal migraine aura. Fever malaise and tingling sensation along a nerve root will be a prodromal sign in case of herpes zoster
- Radiological Signs: A radiological sign is an “objective” indication of some medical fact or quality that is detected by a physician during examination of a radiograph. e.g., Tail's Sign in Ranula and Trap door sign in floor of orbit fractures
- Vital Signs: Vital signs are the observable and measurable signs of life. These include the following: pulse, respiratory rate, body temperature and blood pressure. It can be defined as body's physiological status and provide information critical to evaluating homeostatic balance. Assessment of Pain is referred as fifth vital sign. However some authors do recommend ECG, Oxygen saturation and Tobacco use as fifth vital sign. Vital signs are taken daily or only once in week. However in critically ill patients the machines are attached
- Warning sign: Warning signs are an indication of some hazardous event which is likely to occur and which is not obviously detectable. E.g., Chest discomfort and shortness of breath are the warning signs associated with heart attack.
| Clinical Signs|| |
The Asboe-Hansen sign (“indirect Nikolsky sign” or “Nikolsky II sign” or “bulla spread sign”) denotes to the spread of a blister to neighboring unblistered skin when pressure is applied on the top of the bulla.
This sign is named after Sir Gustav Asboe-Hansen (1917–1989).
The Asboe-Hansen sign in fact could be considered as a variation of the bulla spread sign. It applies to smaller, intact, tense bullae where the pressure is applied to the center of the blister.
In the traditional “bulla spread” sign also called, the Lutz sign, margin of an intact bulla is first marked by a pen. Slow and careful unidirectional pressure applied by a finger to the bulla causes the bulla to extend beyond the marked margin. While a regular rounded border is observed in bullous pemphigoid and other sub epidermal blistering disorders, irregular angulated border is seen in pemphigus vulgaris. The sign may also be elicited on a burst blister if an adequate portion of the roof is intact.
The bulla spread sign is positive in all varieties of blistering diseases like the pemphigus group of diseases and many cases of subepidermal blisters, including bullous pemphigoid, dermatitis herpetiformis, epidermolysis bullosa acquisita, cicatricial pemphigoid, dystrophic epidermolysis bullosa, bullous drug eruptions, Stevens-Johnson syndrome More Details and toxic epidermal necrolysis, in acute bullous lichen planus. Due to fragility of the roof of the blister Asboe Hansen sign is usually negative in Hailey-Hailey disease More Details and staphylococcal scalded skin syndrome.
Asboe-Hansen is also eponymously remembered for Asboe-Hansen's syndrome, which is the initial phase of the Bloch-Sulzberger syndrome.
Axillary Freckle sign (Crowe sign)
It is characteristics of Neurofibromatosis showing café-au-lait macules in axilla. These macules almost always develop years before neurofibromas. They can be distinguished from a freckle (ephelis) by their larger size and their occurrence on areas not exposed to the sun. These develop in 90% of NF-1 related patients especially in middle of childhood.
Sir Heinrich Auspitz (1835–1886) described the appearance of a red, glossy surface with pinpoint bleeding on removal of the scale by scraping or scratching in psoriasis. This happens as a consequence of removal of suprapapillary epithelium which is followed by rupture of dilated dermal capillaries. The test by which Auspitz sign is elicited is called as Grattage test. It is also seen in Darier's disease and actinic keratosis.,
Bon Bon sign
It is said to be typical of the stereotypic orolingual movements of tardive dyskinesia. It involves involuntary pushing of the tongue against the inside of the cheek along with chewing and smacking of the mouth and the lips and rolling of tongue in the mouth. These signs may help to distinguish tardive dyskinesia from chorea, although periodic protrusion of the tongue (flycatcher, trombone tongue) is common to both. Tongue will often protrude, have vermicular contraction.
A visible pulsation of the arteries within the nostrils; said to indicate aneurysm of the thoracic aorta.
It is named after, Sir William Henry Battle (1855–1936). It occurs after fracture of the base of the skull in the posterior cranial fossa. Blood collects beneath the fascia and this results in discoloration at the mastoid process. Battle's sign is highly specific and predictive for the basal skull fracture.
Cluster of jewels sign (string of pearls or rosettes sign)
It refers to an early stage of chronic bullous disease of childhood when new lesions appear at the margin of older ones resembling a cluster of jewels. The peculiar appearance of vesicles in an annular pattern or along the edge of a lesion is frequently seen in linear IgA disease. It is not pathognomonic and may also be observed in bullous pemphigoid.
Carpet tack sign (cat's tongue sign, tin tack sign)
It is a useful clinical feature in diagnosing discoid lupus erythematosus (DLE). Hyperkeratotic scales spreading into the follicular infundibulum produces keratotic spikes when viewed from the scale's undersurface mimicking a carpet tack. It can be seen in lichen planus and pemphigus foliaceus.,,,,
Sir Jules Comby, (1853-1947) described Comby sign. It is an initial sign of measles, comprising of thin whitish patches on the gingiva and buccal mucosa, formed of desquamating epithelial cells.
It was described by Sir William Thomas Corlett (1854-1948). It is a contagious bullosa form of impetigo beginning on the face.
Chovstek sign (Chvostek-Wiess sign)
It is given by Frantisek Chvostek (1835-1884) in 1876. The Chvostek sign is one of the signs of tetany seen in hypocalcaemia. It refers to an abnormal reaction to the stimulation of the facial nerve.
Chvostek I Phenomenon – Contracture of facial muscles occurs by tapping on the facial nerve at a specific point. The point is located 0.5 to 1 cm lower to the zygomatic process of the temporal bone, 2 cm front to the ear lobe, and on a line with the angle of mandible.
Chvostek II Phenomenon - It can be produced by tapping on different location of the face. The point is located on the line joining the zygomatic prominence and corner of mouth, 1/3 rd of distance from the zygoma.
This sign may also be encountered in respiratory alkalosis, such as that seen in hyperventilation, Rickets, Diphtheria, Measles, Scarlet fever, whooping cough, Myxedema.
Chagas–Mazza–Romaña's sign (eye sign or Romaña's sign)
Sir Cecilio Roman˜a (1899–1983) described in about eighty percent of cases of Chagas' disease (American trypanosomiasis), there is unilateral swelling of eyelids and orbit after conjunctival inoculation of Trypanosoma Cruzi. Inflammation of the tear gland and preauricular lymphadenopathy are seen.
In dotted Q sign, one or more flies rest on the Patient's tongue which is protruding out of mouth (thereby called as the doted the Q). This sign is indicative that the patient is long dead.
Forchheimer's sign refers to an enanthem of red macules or petechiae confined to the soft palate in patients with rubella. The sign presents in up to 20% of patients during the prodromal period or on the first day of the exanthema.
Forchheimer's sign refers to an enanthem of red macules or petechiae confined to the soft palate in patients with rubella. They may extend on hard palate. Generally arises with the rash, becoming evident in about 6 hours after the first symptom and don't last longer than 12-14 hours. In about 20% of the patients it appear during prodromal period or on the first day of the exanthema. Similar situation seen in Infectious mononucleosis and has been termed as Forchheimer's spots.
Hypertrophic Lichen Planus (LPH) is most pruritic form of Lichen Planus and Fountain sign is seen during intralesional injections, while injecting the plaques of LPH with corticosteroids by a 26G needle, it has been often found that the medicine comes out through the follicular openings in a jet mimicking a “fountain.”
Jean Alfred Fournier (1832 –1914), French dermatologist, mentioned scars on the mouth following the healing of lesions in congenital syphilis.
Sir Robert James Gorlin (1923-2006), an American oral pathologist and geneticist described Gorlin's sign for the first time. It is seen in patients with Ehlers-Danlos syndrome More Details. It is used to describe the ability to touch the tip of the nose with the extended tongue.
Guerin sign (Guérin fracture)
Sir Alphonse François Marie Guérin (1816-1895) described Guerin's sign in Le Fort I Fracture. It is bruising and ecchymosis in the palate in the region of the Greater palatine arteries. Which results from a force of injury directed low on the maxillary alveolar rim in a downward direction.
Hertoghe's sign (Queen Anne's sign)
It is defined as loss of lateral one third of eye-brows (superciliary madarosis). It is seen in leprosy, myxedema, follicular mucinosis, atopic dermatitis, trichotillomania, ectodermal dysplasia, discoid lupus erythematosus, alopecia areata, syphilis, ulerythema ophryogenes, systemic sclerosis, HIV infection, and hypothyroidism.
It is a clinical sign seen in pyodermas and secondarily infected vesiculobullous disorders (e.g., pemphigus, bullous pemphigoid, and linear IgA dermatosis), where there is a transverse fluid level comprising of purulent material at the bottom when the patient is in a standing position.
Hutchinson's nose sign
Hutchinson's nose sign refers to the presence of vesicles occurring on the tip of the nose in patients with herpes zoster., This appearance specifies that the nasociliary branch is affected and that eye involvement may be present or forthcoming; therefore an ophthalmologic assessment is essential.
In grave's disease, absence of forehead wrinkling when gaze is directed upward.
It is seen in patient with Myofascial pain dysfunction syndrome, When a Myofascial trigger point is detected and palpated the patient gives a typical behavioral reaction, acknowledging the tenderness felt in the area of pain reference, known as the 'jump sign' or it is involuntary withdrawal of stimulated muscle, when taut bands are palpated on trigger points. It is characteristic of Fibromyalgia of cervical spine.
Mouth mirror sign
The tests are Lip stick test and Tongue blade sign. Saliva would normally wet mucosa and aid in cleansing teeth. In Lipstick sign the presence of Lipstick or shed epithelial cells on labial surfaces of maxillary anterior teeth is indicative of reduced saliva while positive tongue blade sign indicates that the tongue blade when gently pressed against mucosa will adhere the tissue. This tongue blade sign is also called as mouth mirror sign. It is seen in hyposalivation.
William Ogle (1827-1912) described this as decrease in the sense of smell as leukoderma spreads.,
Violet colored teeth that have an opalescent iridescence. A sign of dentinogenesis imperfecta. This sign when found in a patient with blue sclera indicates the presence of osteogenesis imperfecta.
Oxalic sign (Lemon Salt sign, Sorrel Salt sign)
Burning pain in oral cavity and pharynx with vomitus comprising of white lumps of mucous and altered brown or black blood. Stains on skin and mucous membranes appear white or brown and stains on clothing appear brown or orange. A sign of poisoning with oxalic acid.,
When the mouth lays open in a perfect geometric round shape for hours at a time is called as 'O' sign. Patient has agonal respiration, gaping mouth and is near death. The mouth is in the shape of an 'O' hence it is called as 'O' sign It indicates poor prognosis.
Discrete red or violaceous papules in the nail bed may lift and split the overlying nail plate longitudinally, and split lateral edges angle forward to give a pup tent appearance. This has been referred as pup tent sign.
Refers to the persistence of the nevus of Ota in the periorbital location following laser therapy, whereas other peripheral sites clear well.
Panda sign (Racoon eye)
It is seen in basilar skull fracture., The situation is appreciated as periorbital ecchymosis from subconjunctival hemorrhage, which happens as a consequence of blood dissecting from the disrupted skull cortex to the soft tissue of the periorbital region.
Patient dead. Tongue now lagging out of mouth (there by changing the O to a Q).
Named after British psychiatrist Gerald Russell (1928-2018). It is seen in patients with bulimia nervosa owing to repeated contact of the incisor teeth with the skin and during self-induced vomiting or gag reflex at the back of the throat with their finger. It denotes to the lacerations, abrasions, and callosities that are seen on the dorsum of the hand covering the metacarpophalangeal and interphalangeal joints.
This type of scarring is considered one of the physical indicators of a mental illness, and Russell's sign is primarily found in patients with an eating disorder such as bulimia nervosa or anorexia nervosa. However, it is not always a reliable indicator of an eating disorder.
Named after, Sir Armand Trousseau, (1801–1867), it is a test for latent tetany in which carpal spasm is induced by inflating a sphygmomanometer cuff on the upper arm to a pressure exceeding systolic blood pressure for 3 minutes. A positive test may be seen in hypocalcaemia and hypomagnesaemia. Occlusion of the brachial artery causes flexion of the wrist and metacarpophalyngeal joints, hyperextension of the fingers and flexion of the thumb on the palm producing the characteristic posture called main d' accoucheur.
It is seen in subcutaneous lipoma, the edges are well defined and when pressed it slips away.
Furrows radiating from the mouth in congenital syphilis.
Used earlier as an indication of the start of nerve regeneration It is elicited by percussion over the divided nerve, which results in tingling sensation in the part supplied by the peripheral section.
It is the presence of small erosions of molars and bicuspids in the cervical region. The erosions are shallow and have dark hue. It is more common in diseases of the liver associated with biliary disorders in which there is an increase in the quantity of biliary substances in the plasma. Oral manifestaions of hepatopathies include Vincent's sign and Teti's sign.,
It is the presence of cuneiform erosions in the cervical regions of adult teeth which appears to be associated with disease of the liver.
It is an invasive granulomatous lesion destroying the bridge of nose and affecting the sinuses described by Sir Friedrich Wegner (1907-1990).
| Radiological Signs|| |
It is subperiosteal erosion of the radial surface of middle phalanges of the second and third digits may be the sensitive indicator of secondary hyperparathyroidism.
Holman-Miller sign (Antral sign, Bow sign)
Anterior displacement of posterior antral wall on various radiographs like lateral plain radiograph, panoramic radiograph and CBCT is termed as Bow Sign. It also shows sinus opacifications. It is most commonly seen in juvenile nasopharyngeal angiofibroma. This is a non-specific sign that can be produced by any slowly growing mass.
It is a widening of periodontal ligament space symmetrically on radiographs and an early sign of Osteosarcoma. It is also seen in chondrosarcoma.
Tear drop sign
Blow out fracture of inferior orbital margin. This injury occurs when an object (e.g., ball) hits the eye rather than zygoma. The contents of the orbit are pushed down through orbit since it is weakest point.
The inferior rectus muscle is trapped causing diplopia on upward gaze. The classical appearance on X-ray is ball of proptosed tissue described as “Tear Drop” appearance. If this sign is observed the patient is not supposed blow through nose.
Stafne's sign is seen in progressive systemic sclerosis. Widening of the periodontal ligament space secondary to increase in the collagen synthesis and increase in the bulk of the ligament, this is accommodated at the expense of alveolar bone, thus causing an increase in the width of the periodontal ligament space.
It is seen in Laryngitis and Laryngotracheobronchitis. Neck radiography demonstrates subglottic narrowing (a finding termed “steeple sign”) on an anteroposterior view.
Tail sign (Comet sign)
It is an extension of ranula from sublingual gland in the sublingual space, commonly seen on CT and MRI. It is core of CT diagnosis of plunging ranula. It provides an important clue to differentiate plunging ranulas from other cystic lesions arising in or near submandibular space such as cystic hygroma, Thyroglossal duct cyst, Second brachial cleft cyst, Abscess and dermoid/epidermoid cyst. A dividing ranula has a distinct tail sign within sublingual space with bulk of cyst seen in submandibular space.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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