NURSING SENSORY PERCEPTION SYSTEM
GUSTATORY
LECTURER:
Ns. Leni Merdawati, M.Kep
MEMBERS OF GROUP V:
Muhammad Ilham Zul (1511314001)
Faradila Lorenza (1511314004)
Nadia Qonita (1511314012)
Ridha Hayati (1511314015)
Muthia Tri Zuhriani (1511314018)
NURSING FACULTY
ANDALAS UNIVERSITY
PADANG
2016/2017
PREAMBLE
Praise be to God Almighty for His grace and mercy , so that we can complete a
paper on Sensory Perception System.
We thanks all those who have helped in completing this paper , particularly our
lecturers who has guided us to this paper resolved .
We realize this paper is far from perfect becouse of that ,criticisms and suggestions
from readers so we need to repair this paper . And hopefully this paper can be useful for us
and readers
Padang. January,29. 2017
CHAPTER I
INTRODUCTION
A. Background
In humans, the sense of taste is transduced by taste buds and is conveyed via three of
the twelve cranial nerves. Cranial nerve VII, the facial nerve, carries taste sensations
from the anterior two thirds of the tongue (excluding the circumvallate papillae, see
lingual papilla) and soft palate. Cranial nerve IX the glossopharyngeal nerve carries
taste sensations from the posterior one third of the tongue (including the circumvallate
papillae). Also a branch of the vagus nerve carries some taste sensations from the back
of the oral cavity (i.e. pharynx and epiglottis). Information from these cranial nerves is
processed by the gustatory system. Though there are small differences in sensation,
which can be measured with highly specific instruments, all taste buds can respond to
all types of taste. Sensitivity to all tastes is distributed across the whole tongue and
indeed to other regions of the mouth where there are taste buds (epiglottis, soft palate).
B. Formulation of Problem
1. How the anatomy and fisiolgy about Gustatory ?
2. What is definition of Gustatory Disorder?
3. How etiology of Gustatory Disorder?
4. What is clinical symptoms of Gustatory Disorder?
5. What the treatment of Gustatory Disorder?
6. How the functional gordon for Gustatory Disorder?
CHAPTER II
GUSTATORY
A. Anatomy and Fisiology
1. Papilla
Papilla are specialized epithelial cells. There are four types of papillae: filiform
(thread-shape), fungiform (mushroom-shape), foliate (leaf-shape), and
circumvallate (ringed-circle). All papillae except the filiform have taste buds on
their surface. Some act directly by ion channels, others act indirectly.
a. Fungiform papillae - as the name suggests, are slightly mushroom shaped if
looked at in section. These are present mostly at the apex (tip) of the tongue.
b. Filiform papillae - these are thin, longer papillae that don't contain taste buds
but are the most numerous. These papillae are mechanical and not involved in
gustation.
c. Foliate papillae - these are ridges and grooves towards the posterior part of the
tongue.
d. Circumvallate papillae - there are only about 3-14 of these papillae on most
people and they are present at the back of the oral part of the tongue. They are
arranged in a circular-shaped row just in front of the sulcus terminalis of the
tongue.
2. Structure of Taste Buds
Each taste bud is flask-like in shape, its broad base resting on the corium, and
its neck opening by an orifice, the gustatory pore, between the cells of the
epithelium.
The bud is formed by two kinds of cells: supporting cells and gustatory cells.
The supporting cells are mostly arranged like the staves of a cask, and form
an outer envelope for the bud. Some, however, are found in the interior of the bud
between the gustatory cells. The gustatory cells occupy the central portion of the
bud; they are spindle-shaped, and each possesses a large spherical nucleus near the
middle of the cell. The peripheral end of the cell terminates at the gustatory pore in a
fine hair-like filament, the gustatory hair.
The central process passes toward the deep extremity of the bud, and there
ends in single or bifurcated varicosities.
The nerve fibrils after losing their medullary sheaths enter the taste bud, and
end in fine extremities between the gustatory cells; other nerve fibrils ramify
between the supporting cells and terminate in fineextremities; these, however, are
believed to be nerves of ordinary sensation and not gustatory.
3. Types of Taste
a. Salt
Arguably the simplest receptor found in the mouth is the salt (NaCl) receptor.
An ion channel in the taste cell wall allows Na+ ions to enter the cell. This on its
own depolarizes the cell, and opens voltage-regulated Ca2+ gates, flooding the
cell with ions and leading to neurotransmitter release. This sodium hannel is
known as EnAC and is composed of three subunits. EnAC can be blocked by
the drug amiloride in many mammals, especially rats. The sensitivity of the salt
taste to amiloride in humans, however, is much less pronounced, leading to
conjecture that there may be additional receptor proteins besides EnAC that may
ot have been discovered yet.
b. Sour
Sour taste signals the presence of acidic compounds (H+ ions in solution). There
are three different receptor proteins at work in sour taste. The first is a simple
ion channel which allows hydrogen ions to flow directly into the cell. The
protein for this is EnAC, the same protein involved in the distinction of salt taste
(this implies a relationship between salt and sour receptors and could explain
why salty taste is reduced when a sour taste is present). There are also H+ gated
channels present. The first is a K+ channel, which ordinarily allows K+ ions to
escape from the cell. H+ ions block these, trapping the potassium ions inside the
cell (this receptor is classified as MDEG1 of the EnAC/Deg Family). A third
protein opens to Na+ ions when a hydrogen ion attaches to it, allowing the
sodium ions to flow down the concentration gradient into the cell. The influx of
ions leads to the opening of a voltage regulated Ca2+ gate. These receptors
work together and lead to depolarization of the cell and neurotransmitter release.
c. Bitter
There are many classes of bitter compounds which can be chemically very
different. It is interesting that the human body has evolved a very sophisticated
sense for bitter substances: we can distinguish between the many radically
different compounds which produce a generally “bitter” response. This may be
because the sense of bitter taste is so important to survival, as ingesting a bitter
compound may lead to injury or death. Bitter compounds act through structures
in the taste cell walls called G-protein coupled receptors (GPCR’s). Recently, a
new group of GPCR’s was discovered, known as the T2R’s, which is thought to
only respond to bitter stimuli. When the bitter compound activates the GPCR, it
in turn releases gustducin, the G-protein it was coupled to. Gustducin is made of
three subunits. When it is activated by the GPCR, its subunits break apart and
activate phosphodiesterase, a nearby enzyme. It then converts a precursor within
the cell into a secondary messenger, which closes potassium ion channels. This
secondary messenger can stimulate the endoplasmic reticulum to release Ca2+,
which contributes to depolarization. This leads to a build-up of potassium ions
in the cell, depolariza ion, and neurotransmitter release. It is also possible for
some bitter tastants to interact directly with the G-protein, because of a
structural similarity to the relevant GPCR.
d. Sweet
Like bitter tastes, sweet taste transduction involves GPCR’s. The specific
mechanism depends on the specific molecule. “Natural” sweeteners such as
saccharides activate the GPCR, which releases gustducin. The gustducin then
activates the molecule adenylate cyclase, which is already inside the cell. This
molecule increases concentration of the molecule cAMP, or adenosine 3', 5'-
cyclic onophosphate. his protein will either directly or indirectly close
potassium ion channels, leading to depolarization and eurotransmitter release.
Synthetic sweeteners such as saccharin activate different GPCR’s, initiating a
similar process of protein transitions, starting with the protein phospholipase A,
which ultimately leads to the locking of potassium ion channels.
Taste and smell are interdependent, and difficulty with one is sometimes interpreted as a problem
with the other. Loss of taste occurs when there is a disturbance in the saliva or the surroundings
of the taste cells.22 Normogeusia is the name given to normal taste. Loss or impairment of taste
can occur in degrees:
• Hypogeusia, diminished taste
• Dysgeusia, distorted taste
• Aliageusia, altered taste, usually pleasant
• Phantogeusia, persistent abnormal taste in the absence of a stimulus
• Ageusia, no taste.
Conditions that can lead to loss of taste include:
• Aging
• Inflammation in the mouth
• Infection that reduces blood flow to the tongue and interferes with saliva production and
leads to injury of cell receptors
• Gastric reflux (a common cause)
• Systemic conditions such as diabetes mellitus, Sjögren syndrome, pernicious anemia, and
Crohn disease.
B. Pathophysiology
GLOSSODYNIA
Defenition Glossodynia
Burning mouth syndrome (BMS) is defined by the International Association
for the Study of Pain as a burning pain in the tongue or other oral mucous membranes
associated with normal signs and laboratory findings. The condition is now thought to be
an intraoral form of neuropathic pain.
Etiology Glossodynia
Different factors have been proposed for secondary BMS as follows:
1. Local Factors
a. Oral conditions: Lichen planus, geographic tongue
b. Oral habits: Tongue thrusting, bruxism
c. Excessive mouth irritation: Overbrushing, overuse of mouth washes,
overingestion of acidic drinks.
2. Systemic Factors
a. Xerostomia caused by various health problems like Sjogren’s syndrome and
radiation therapy.
b. Gastroesophageal reflux disease (GRED)
3. Nutritional Factors
Deficiencies of B vitamins 1, 2, 6 and 12, as well as zinc, folate and iron,
have been suggested as causes of secondary BMS, occurring from direct neurologic
damage or in relation to anemia.
4. Allergic or Immunological Factors
Elevated erythrocyte sedimentation rate (ESR) and salivary IgA levels is seen
in BMS patients suggestive of immunologic or allergic phenomenon. Allergies are
seen in type 3 BMS as intermittent symptoms, associated with signs of mucosal
irritation. Suggested irritants include dental materials such as mercury (present in
amalgam), methyl methacrylate, cobalt chloride, zinc and benzoyl peroxide.
Components of lotions such as petrolatum cadmium sulfate, octyl gallate, benzoic
acid and propylene glycol have been implicated. Food allergens include peanuts,
chestnuts, cinnamon, nicotinic acid and sorbic acid.
5. Psychological Factors
Patients with BMS show increase in salivary cortisol level indicating higher
levels of stress. However, anxiety and depression are considered as exacerbating
factors rather than the cause of BMS as the symptoms disappear following their
remission.
6. Iatrogenic Factors
Drug-associated BMS have been observed with use of angiotensin-
converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). The
product of inflammatory reaction generates increased bradykinin. The mechanism is
clearly not understood but kallikrein, a molecule active in the kinin pathway, is
increased in the saliva of BMS patients, resulting in increased inflammation. Other
drugs like antiretrovirals nevirapine and efavirenz may also result in BMS.
However, the mechanism is not clearly understood.
7. Infections
Few microbes like Candida, Enterobacter, Fusospirochetes, Helicobacter
pylori and Klebsiella are prevalent in patients with BMS without visible mucosal
lesions.
8. Endocrine Disorders
Menopause, whether surgical or physiological, is associated with higher
prevalence of BMS. The mechanism is unclear but hormonal alterations may
possibly affect the oral mucosa. Estrogen has documented effects on oral mucosa,
and deprivation may lead to atrophic changes thereby altering stimulation of the
nerve endings within the epithelium. Alternatively, atrophic epithelia may be more
prone to inflammation.
Thyroid hormones are involved in maturation and specialization of taste buds
and recent studies have shown that thyroid hypofunction may be responsible for
hypogeusia, for bitter taste and for the release of inhibitions for sensitive trigeminal
sensation.
9. Neurological Disorders
Sensory testing has revealed taste deficits and heat/pain intolerance among
BMS patients due to an abnormal interplay between the sensory function of chorda
tympani and lingual nerve either in the peripheral or central nervous systems
resulting in BMS.
Manifestation Glossodynia
1. Painful teeth, jaw and temporomadibular joint
2. Loss of a comfortable jaw position and uncontrollable jaw tightness
3. Headache, neck and shoulder pain
4. Increased parafunctional activity
5. Difficulty in speaking, nausea, gagging and dysphagia
6. Usually bilateral but can be unilateral as well
7. Multiple mood and emotional disturbances
Treatment Glossodynia
increase dietary intake of vitamin B, folic acid, iron and use of vitamin supplements
etc under medical supervision if blood tests confirm low concentrations
institute topical antifungal therapy if fungal plaques noticed
psychological counselling for emotional shock
there are no simple treatments that have proven to be effective in the majority of patients,
however, two patient case studies discuss the individual approach taken for each patient
HYPOGEUSIA
Defenition Hypogeusia
Hypogeusia is a category of taste disorder in which those who suffer show
symptoms of a decreased ability to taste difference in foods (Naik & Claussen, 2010).
Etiology Hypogeusia
Hypogeusia are related to socioeconomic level, alcohol and drug use, and
certain surgeries. Diagnostic tests are usually preformed using a filter paper test and
treatment is still experimental.
In regards to hypogeusia, one sole cause has not been found, but it is most
common among those of middle level education. Due to their educational level their
socioeconomic level is usually lower and their jobs have higher health risks within the
work place. Also, due to the lower pay, that often accompanies a lower socioeconomic
job, it does not allow for the healthy living conditions in which they are exposed to
harmful toxins and chemicals, which may also be a large contributor of hypogeusia
(Caldas, et al., 2013).
Along with and related to socioeconomic causes, hypogeusia has been
correlated with those who receive a laryngectomy. Hypogeusia occurs in approximately
80% of larygectomy patients. During the surgery disruption of airflow in the respiratory
tract and changes to the epithelial structure ofthe nasal mucosa contribute to the cause of
hypgeusia. Those who receive a laryngectomy are correlated with patients who are,
again, of low education. They are also, usually, frequent smokers and have a history of a
high alcohol intake, both of which cause damage to the taste buds and could be an
underlying factor to the cause of hypogeusia. Another cause of hypogeusia could be the
mere aging process. Out of 71 elderly subjects 36% reported symptoms of hypogeusia.
This may be due to a correlation between hyposalivation and hypogeusia that suggest
proper salivation prevents the occurrence of hypoguesia, an due to the reduction of
proper salivation with age hypogeusia may be a factor of getting older. (Sasano, et al.,
2010). Another surgery that has been connected to hypoguesia has been ear surgery
involving the chorda tympani. Of the 45 patients that underwent ear surgery of the
chorda tympani, 53% reported symptoms of hypogeusia. It was also reported that males
were more sensitive to taste alterations than women. An interesting outcome of the
surgery in relation to hypogeusia was only half of the tongue was experiencing the taste
alterations in those who suffered. It was reported that the side of the tongue opposite that
of the chronic otitis media did not experience any alterations (Felix, et al., 2009). The
diagnosis of hypogeusia is standard in the fact that a filter paper test is used. Four
different tastants are distributed to patients at different concentrations. The patients’
ability to detect the different tastants, and each of their concentrations, allows for better
discrimination of the degree of taste alteration (Sasano, et al., 2010).
Manifestation Hypogeusia
Treatment Hypogeusia
Treatment of hypoguesia can consist of treating hyposalivation but the
treatment that diminishes hyposalivation can have several aversive effects such as
palpitations, sweating, nausea, diarrhea, and dizziness in older patients. A surgical way
to help diminish hypogeusia is to remove either submandibular or sublingual glands that
cause a reduction of the taste nerve and increase taste threshold. Through this treatment it
is seen that proper salivation is necessary for normal taste functioning. A new study is
looking into the use of umami as a relief of hypogeusia. This technique is still being
experimented with but would allow a relief of the taste abnormality without the adverse
side effects that come with medication or surgery and is stemmed from the theory that
umami may have a higher threshold compared to the other four tastants, salt, sweet, sour,
bitter (Sasano, et al., 2010).
AGEUSIA
Definition Ageusia
Ageusia is a category of taste disorder in which those who suffer show
symptoms of an absence of taste all together. Causes of ageusia are not well known but
seem to be connected to damage done to the cortex and central pathways and drug use. It
is also speculated that specific surgeries and drugs can be a contributor to the cause of
ageusia. Diagnosis of ageusia is rare due to its symptoms not being pronounced in some
humans. Treatment of ageusia is still under research but in most cases symptoms can be
decreased by the termination drug use.
Etiology Ageusia
Due to the rarity of aguesia, the causes of ageusia cannot be simply narrowed
down. The causes range from surgery accidents to medications. Ageusia can be
explained in some situations, however, as a consequence to damage done to the cortex
and central pathways that are responsible for taste (Ribas & Duffau, 2012). Ageusia can
also be caused by the use of medications, in in particular; one medication that has been
found to correlate with ageusia is clopidogrel. Clopidorgrel is a new thienopyidine
derivative and is used as a secondary preventative in patients with atherosclerosis,
coronary artery disease, and those who suffer from ischemic attacks (Ksouda, et al.,
2011).
Manifestation Ageusia
For those who do suffer from ageusia and are diagnosed report having a
decrease in appetite. In terms of aguesia as a side effect to Clopidorgrel, it is not life
threatening but can severely affect patients’ quality of life. It does however lead to
continual looping effect in which patients have a loss of appetite, lose weight, and
require discontinuation of said drug, which then leads to a higher risk of atherosclerosis,
coronary artery disease, and ischemic attacks (Ksouda, et al., 2011).
Treatment Ageusia
Treatment for ageusia is still being researched but due to the rarity of
diagnosis of the disorder not much can be looked into. As of right now the best solution
to the disorder are the options of discontinuing a causal drug use (Ksouda, et at., 2011).
Another possibility is to do more routine check ups for those that undergo
surgery or take medications linked with partial ageusia. Dietary counseling should also
be put into place so that those who suffer from ageusia learn to have a better relationship
with their food and improve their quality of life.
DYSGEUSIA
Defenition Dysgeusia
Dysgeusia is a category of taste disorder in which those who suffer describe
the presence of a metallic, foul, or rancid taste in their mouth without any physiological
causes (Naik & Claussen, 2010). Also, many patients who suffer from dysgeusia report a
spontaneous bitter taste when eating sweet items (Hsiao & Li, 2007).
Etiology Dysgeusia
The cause of dysgeusia has been linked to cancer patients receiving
chemotherapy and adiation therapy. Causes are also related to specific drug use and
correlated with ocioeconomic levels.
There have been several factors found to be a cause of dysgeusia but the most
common causes are chemo and radiation therapy. It is estimated that over all 50-75% of
cancer patients are affected by dysgeusia. The rate of dysgeusia is strongly correlated
with the accumulation of radiation therapy sessions (Mosel, Bauer, Lynch & Hwang,
2011). In more relation to cancer, chemotherapeutic drugs such as cisplatin, doxorubicin,
5-fluorouracil (5-FI), docetaxel, and paclitacel cause dysgeusia (Imai, et al.). Dysgeusia
in chemotherapy patients can be xplained through neurological damage done to the
cranial nerves: VII, IX, and X, taste buds, and ucosal damage (Imai, et al.). Other causes
may be due to infections of the mouth from bacterial, fungal, and viral agents (Mosel, et
al, 2011). As seen with hypogeusia, those with lower education and lower socioeconomic
ranking are at higher risk for developing dysgeusia due to their jobs. Due to the exposure
of ammonia, wood dust, chromium, and hydrocarbon solvent mixtures of many
construction and factory workers their risk is high. Also, common chemicals such as
those from hairdressing, chemotherapy, gasoline, and intranasal zinc have been shown to
cause dysgeusia (Smith, et al., 2009). Other causes of dysgeusia have been linked to
diabetic neuropathy (Ishimaru, Hatanaka, Miwa & Furukawa, 2001), and patients who
receive drug therapy of Fluorouracil (5FU) (Imai, et al.).
Manifestation Dysgeusia
As an effect of dysgeusia on quality of life, patients have a substantial
amount of weight loss and a reduction of nutrient intake. This is due to the rancid taste
they may experience while eating or the lack of hunger due to a constant unpleasant taste
experience, even with the absence of food (Karita, et al., 2012).
Treatment Dysgeusia
Dysgeusia is most correlated with those who receive chemo or radiation therapy, which
may cause damage to the oral mucosa and taste buds. An interesting test to add to the
diagnostic process for dysgeusia would be a taste bud count. Due to the occasional fade
or resolution of dysgeusia after a few months allows us to infer dysgeusia may be caused
by problem with taste bud turn over rate, in which the taste buds are not regenerating at a
normal rate and therefore causing taste disruptions. It has been identified that a decrease
in estrogen is correlated to lessening symptoms of dysgeusia. It has also been seen that
zinc and antibiotics can be used to heal the oral mucosa and possible help regenerate
taste buds decreasing the symptoms of dysgeusia. Seeing as chemo and radiation therapy
are necessary, the best form of treatment is dietary counseling in which patient’s learn to
live with the disturbances but find techniques to minimize the effects they have on their
quality of life.
CASE;
Mr. K. 25 years of coming to the hospital with complaints of pain and discomfort
and the blisters surrounded by red areas form a bubble liquid in the lip area. Mr K
previous experience itching for 2 days. Mr K complained of pain. Mr. K's face
looked painfully. Mr. K also said no appetite for hard to chew and swallow. Mr. K's
wife says clients can just spend 5 sendik eat rice every makan.Dari physical
examination results in the lips Mr. K are reddish spots, awareness composmetis, the
temperature of 37.50 C, a blood pressure of 130 / 90mmHg, Nadi 112x / m, BB
down from 65 to 60 kg. Leukocytes <4000 / mmk
ASSESSMENT OF FUNCTIONAL PATTERN GORDON ( HERPES SIMPLEX)
A. The pattern of health management
Patients say if there is a sick family then immediately brought the nearest health
facility both the clinic and the doctor.
B. nutritional pattern
Before ill patients eat with moderation 3 times a day plus snacks and drinking 4 cups /
day. But when pain patients appetite is reduced, but not to a loss of appetite. At the
hospital the patient is still able to spend the meal portions.
C. patterns of elimination
For bowel and bladder patients do not experience interruption during his illness that
BAB 1x and 4x BAK.
D. The pattern of perceptual and cognitive
Patients did not experience disorientation of time and place. All patients sensory organs
are still functioning within normal limits.
E. The pattern of activity
Patients move as usual is going to the office to work, and perform other activities in
accordance with the routine.
F. The pattern of sleep and rest
Before the pain of patients had no complaints with their sleep habits are 6- 8 hours / day.
When ill patients sometimes complain it difficult to sleep because of pain.
G. The pattern of self-perception and self-concept
Patients know the disease condition today and will try to accept all current condition.
Patients do not feel embarrassed and inferior to the current condition.
H. The pattern of roles and relationships
Patients did not experience problems in their social relations. Patient is a head of the
family of a wife and a son and the backbone of the economy of his family beside his
wife.
I. The pattern of sexuality and reproduction
Patient sex male - male, was married with a wife and have a child.
J. Coping patterns and stress tolerance
Patients feel confident that eventually the disease will be cured, but it should require an
effort and do not forget to continue to pray.
K. The pattern of values and beliefs / religion
Patients still run the regular worship
CHAPTER III
CONCLUTION
A. Conclution
BMS is a difficult and challenging problem for the dental practitioner. It is a
clinical diagnosis made via the exclusion of all other causes. No universally accepted
diagnostic criteria, laboratory tests, imaging studies or other modalities definitively
diagnose or exclude BMS. The key to successful management is a good diagnostic work-
up and coordination between the dental practitioners and appropriate physicians and
psychologists.
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ElizabethDurham, Jacquel, Jtervortn, Klaitaka, Mohborg, Neoptolemus, Never2late,
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https://sydney.edu.au/medicine/pmri/pdf/Burning-mouth-syndrome.pdf
Indian Journal of Clinical Practice, Vol. 23, No. 3, August 2012
