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IN VITRO EVALUATION OF MARGINAL MICROLEAKAGE IN RESTORATIONS CLASS V WITH COMPOSITE RESINS

AVALIACIÓN IN VITRO DE LA MICROINFILTRACIÓN MARGINAL EN

RESTAURACIONES CLASE V CON RESINAS COMPUESTA

AVALIAÇÃO IN VITRO DA MICROINFILTRAÇÃO MARGINAL EM RESTAURAÇÕES CLASSE V COM RESINAS COMPOSTA

Lara Line Nolêto Martins1, Mariana da Silva Corrêa Nolêto2, Samuel Fontes Batista3, Sabrynna Gonçalves Candeira Portela4, Rosiléia Cardoso Martins5, Patrick Veras Quelemes6, Raony Môlim de Sousa Pereira7, Carlos Alberto Monteiro Falcão8, Maria Ângela Arêa Leão9 1 – Universidade Estadual do Piauí – UESPI, Dentist. E-mail: lara_line@hotmail.com 2 - Universidade Estadual do Piauí – UESPI, Dentist. E-mail:mary_scn@hotmail.com 3 - Universidade Estadual do Piauí – UESPI, Dentist. E-mail: samufg1@gmail.com 4 - Universidade Estadual do Piauí – UESPI, Dentist. E-mail:sabrynnagcp@hotmail.com 5 - Universidade Estadual do Piauí – UESPI, Dentist. E-mail: rosileia_cardoso@hotmail.com 6 – Universidade Federal do Piauí – UFPI, PhD in Biotechnology. E-mail: pquelemes@gmail.com 7 - Universidade Estadual do Piauí – UESPI, PhD in Oral Rehabilitation. E-mail: raonymolimsp@hotmail.com 8 - Universidade Estadual do Piauí – UESPI, PhD in Dental Clinics. E-mail: falcaoendo@hotmail.com 9 - Universidade Estadual do Piauí – UESPI, PhD in Endodontics. E-mail: angela.endo@hotmail.com

Maria Ângela Arêa Leão Ferraz (Corresponding author) PhD in Endodontics, Professor at Universidade Estadual do Piauí – UESPI, angela.endo@hotmail.com

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Abstract Objective: Evaluate the marginal microleakage in restorations with three different composite resins. Material and Methods: Thirty premolars were used, where class V cavities were made. The samples were divided into three groups: G1 (Microparticulate), G2 (Micro-hybrid), G3 (Nano-hybrid). After the restorations have been made, the samples were thermocycled for 250 cycles. The teeth were waterproofed and placed in 1% methylene blue solution for 24 hours. Results: The quantitative evaluation of the degree of dye penetration showed that all groups had marginal infiltration, however they had it in varying degrees, highlighting that the nano-hybrid composite resin presented the lowest values of marginal infiltration and the microparticulate composite resin had the highest values, and the group of micro-hybrid and nano-hybrid composite resin did not present statistically significant differences. Conclusion: All the groups evaluated have undergone infiltration to some degree. Keywords: Materials. Dental Restoration, Permanent. Dental restoration failure. Resumén Objetivo: Evaluar la microfiltración marginal en restauraciones con tres resinas compuestas diferentes. Material y Métodos: Se utilizaron 30 premolares, donde se realizaron cavidades de clase V. Las muestras se dividieron en tres grupos: G1 (Microparticulado), G2 (Microhíbrido), G3 (Nanohíbrido). Después de realizar las restauraciones, las muestras se termociclaron durante 250 ciclos. Los dientes se impermeabilizaron y se colocaron en solución de azul de metileno al 1% durante 24 horas. Resultados: La evaluación cuantitativa del grado de penetración del tinte mostró que todos los grupos tenían infiltración marginal, sin embargo la tenían en grados variables, destacando que la resina compuesta nanohíbrida presentaba los valores más bajos de infiltración marginal y la resina compuesta microparticulada tenía la mayor valores, y el grupo de resina compuesta microhíbrida y nanohíbrida no presentó diferencias estadísticamente significativas. Conclusión: Todos los grupos evaluados sufrieron infiltración en algún grado. Palabras-Clave: Materiales. Restauración dental permanente. Fracaso de la restauración dental. Resumo Objetivo: Avaliar a microinfiltração marginal em restaurações com três diferentes resinas compostas. Material e Método: Trinta pré-molares foram utilizados, onde foram feitas cavidades classe V. As amostras foram divididas em três grupos: G1 (Microparticulada), G2 (Microhíbrida), G3 (Nanohíbrida). Após as restaurações terem sido realizadas, as amostras foram termocicladas por 250 ciclos. Os dentes foram impermeabilizados e colocados em solução de azul de metileno a 1% por 24 horas. Resultados: A avaliação quantitativa do grau de penetração do corante mostrou que todos os grupos apresentaram infiltração marginal, porém variaram em graus variados, destacando que a resina composta nano-híbrida apresentou os menores valores de infiltração marginal e a resina composta microparticulada apresentou os maiores valores, e o grupo de resina composta micro-híbrida e nano-híbrida não apresentou diferenças estatisticamente significantes. Conclusão: Todos os grupos avaliados sofreram infiltração em algum grau. Descritores: Materiais. Restauração dentária permanente. Falha de restauração dentária.

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Introduction Dentistry has undergone changes in some of its concepts, being part of the routine of the dental offices and clinics the search for treatments more aesthetic and conservative. Therefore, the resin has been the subject of intense research in order to improve the negative properties that it presents.(1) The utilization of composite resins still requires use criteria and the unrestricted use of this restorative material will only be possible after further development and improvement of its physicochemical properties.(2) The formation of an effective bonding interface between the tooth and the restorative material is one of the determinant factors for the marginal microleakage control.(3) The rupture of the adhesive interface is a failure that frequently occurs in composite resins restorations caused by polymerization shrinkage, resulting in a volumetric reduction.(4) The composite resin has three structural components: organic matrix (a plastic resinous material that forms a continuous phase and binds to the charge particles), inorganic particles (reinforcing particles and / or fibers dispersed in the matrix) and the bonding agent (promotes adhesion between the particles and the resin matrix).(5) The polymerization shrinkage occurs when the monomers (organic part) are transformed into polymers. The more inorganic fillers, the less the amount of organic matrix, the greater the modulus of elasticity.(6) The rupture in tooth-restoration interface may present as clinical consequence the marginal discoloration, marginal fractures, secondary caries, postoperative pain and development of pulpal pathology, all of which endangered the longevity of the restoration.(7,8)

The dental surgeon must know and respect the correct indications of composite resins, aiming the longer permanence of the restorative material in the cavity preparation. Follow strictly the clinical protocol and instruct the patient about how to control the etiological factors of caries disease are ethical duties of a dental professional.(2) Considering the intense search for aesthetics by the population, the composite resin has been the material of choice in most of the restorative procedures performed by the dental surgeon, concomitantly has presented significant rates of failure, arising the interest to investigate which type of resin has lower rates of microleakage and thus less damage to biological tissues and greater longevity. Therefore, this study aimed to evaluate in vitro the marginal microleakage in class V restorations of premolar teeth using three different composite resins as restorative material. Material and Methods

All procedures in this study followed the ethical principles established by the

legislation in force, therefore this study was submitted to Ethics Committee in Research (ECR) from State University of Piauí (UESPI), pursuant to resolution CNS 466/2012 and approved under the CAAE number 4245515.0.0000.5209.

Thirty human premolars were used from UESPI Human Teeth Bank, which were stored in water under refrigeration until the beginning of the procedure. Teeth were submitted to steam sterilization, followed by prophylaxis with prophylactic paste, powdered pumice stone and water.

Class V cavities were made(9,10,11) on the vestibular face, with the following characteristics: 3 mm width (mesiodistal) and 2 mm tall (cervical-occlusal) and 1.5

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mm depth, measures granted by millimetric probe,(10) as well as clear cavo-superficial angles located in enamel.(7,12,13) The cavity preparation was performed with KG Sorensen diamond drills (Cotia, São Paulo, Brasil) n°1095(12) with high speed handpiece. The diamond drill was replaced every 10 cavity preparations.

The 30 premolars teeth were randomly divided into three groups of ten teeth each one and than they were restored with the following materials: G1: microparticulate resin - Durafill® VS (Heraeus Kulzer, Hanau, Germany), G2: micro-hybrid resin - Charisma® Opal (Heraeus Kulzer, Hanau, Germany) and G3: nano-hybrid - Charisma® Diamond (Heraeus Kulzer, Hanau, Germany). The Gluma® 2 Bond adhesive system (Heraeus Kulzer, Hanau, Germany) was used. All materials were used as manufacturer's instructions. Previous prophylaxis has been made, washing and drying and then the acid conditioning was done for 30 seconds in enamel and 15 seconds in dentin. Cavity wash was made with water jet and dried with a light air jet. with microbrush aid (Heraeus Kulzer, Hanau, Germany) the adhesive system was applied on entire cavity surface, allowing it act for a period of 15 seconds, than dried with a gentle jet of air and photoactivated for 20 seconds. The restoration was performed by incremental technique(9,10,13,14) and each layer was photoactivated for 20 seconds (Bio-Art Photopolymerizer, São Carlos, Brazil). After completion of restorations, teeth were stored in distilled water with final polishing and finishing performed after 24 hours.(7,9,12)

In a next step, the samples were thermocycled for 250 cycles at 5 and 55ºC (Biometra Thermal Cycler, Göttingen, Germany) and immersed in saliva phosphate buffer solution (pH 7.4) at each temperature the samples remained for 30 seconds. Subsequently, the dry teeth were waterproofed with two layers of Universal Instant Adhesive Super Bonder(12) (Loctite®, São Paulo, Brazil) and two layers of cosmetic enamel(13) (Risqué®, Barueri, Brazil), except 1 mm around the margin of restoration.(3,13,14)

Afterwards, the dental elements were immersed in 1% methylene blue solution Cinética® (Jand Química, Jandira, Brazil), for a period of 24 hours.(3) After this time the samples were taken out of the solution, washed in running water and dried. The teeth were fixed in a self-cured acrylic resin base (Clássico, São Paulo) and sectioned at the center of the restorations in the longitudinal buccolingual direction(9,10) with a carborundum disk(12) (American Burrs®, Porto Alegre, Brazil) mounted on low-speed handpiece (Kavo, Santa Catarina, Brazil) totaling 60 faces for analysis.

The evaluation of dye penetration was made using a stereoscopic magnifying glass (Nova Optical Systems©, Piracicaba, Brazil) with a tenfold increase,(9) by a single examiner trained for this purpose, based on the scores: Grade 0: no infiltration; Grade 1: dye infiltration until one third of the surrounding wall; Grade 2: dye infiltration until two-thirds of the surrounding wall; Grade 3: dye infiltration until three-thirds of the surrounding wall, reaching or not the bottom wall (Figure 1). (12) Each test piece was analyzed through the Image J program (Version 1.50) and then noted the highest degree of infiltration. And finally the findings of infiltrations were statistically analyzed using Kruskal-Wallis non-parametric test with significance level of 5%.(3,14)

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Image 1. Evaluation of dye penetration with a stereoscopic magnifying with a tenfold increase. A: Grade 0; B: Grade 1; C: Grade 2; D: Grade 3. Source: Direct research.

Results

In this study 30 restorations in premolars were evaluated, totaling 60 faces for the analysis. Of these, 3 faces were eliminated due to the occurrence of microleakage due to the rupture of the tooth-restoration interface caused by stress during thermocycling.

The number of marginal infiltration scores observed on the faces of the three groups for the different composite resins are shown in Table 1.

Table 1. Distribution of marginal infiltration scores observed in each group.

Scores Group 1 (Microparticulate)

Group 2 (Micro-hybrid)

Group 3 (Nano-hybrid)

0 4 10 11 1 7 8 7 2 1 2 1 3 6 0 0

Total 18 20 19

From the sample characteristics, a one-factor Kruskal-Wallis ANOVA was

performed in all three groups. When analyzing the average of the posts, it is verified, according to Table 2, that the group 1 (Microparticulate) presents the highest average, followed by group 2 (Micro-hybrid) and group 3 (Nano-hybrid). The results presented a χ² (chi-square) of 9.41 with an associated probability of 0.009. Therefore, it is concluded that there are statistically significant differences in marginal leakage observed in each group.

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Table 2. Distribution of groups according to sum and average of the stations.

Group Sum of stations Avarage of stations

1 11,67 38,33

2 3,64 26,10

3 2,69 23,21

The comparison between groups, according to Table 3, shows that there was

a statistically significant difference (p<0.05), between G1 x G2; G1 x G3 and that there was no difference between G2 x G3.

Table 3. Comparison between groups.

Samples compared (two to

two)

Difference between the

avarages

Significance

Group 1 X Group 2 8,34 0,02*

Group 1 X Group 3 9,62 0,005*

Group 2 X Group 3 2,16 0,57

Note: *p < 0,05 (significant)

Considering the results found in this research, it was possible to prove that

none of the three resin types were able to prevent marginal microleakage, with all groups presenting values of microleakage. Separately analyzing the restorative material, it was found that while the composite nano-hybrid resin (Group 3) had the lowest values of marginal infiltration, the microparticulate (Group 1) had the highest values. Discussion The resin matrix often consists of Bis-GMA (bisphenol-A glycidyl methacrylate) or UDMA (urethane dimethacrylate). They constitute the chemically active part, as they will establish crosslinks at the time of polymerization, conferring resistance to the material. Due to the high molecular weight, Bis-GMA and UDMA are extremely viscous at room temperature, which makes it difficult to incorporate filler into the resin matrix. To make the material more fluid to be used clinically, the dimethacrylate based diluents TEGDMA (triethylene glycol dimethacrylate) and EDMA (ethylene glycol dimethacrylate) are included, reducing their viscosity. However, the incorporation of these diluents increases the polymerization shrinkage of the composite resins.(15) According to Gonçalves et al.(16), higher amounts of inorganic fillers imply a smaller amount of organic matrix, which is subject to contraction during polymerization. Therefore, the inorganic particles content is inversely related to the percentage of contraction of the material and the tension experienced by the adhesive interface during its polymerization. Increasing inorganic particles content, the polymerization shrinkage, linear expansion coefficient and water absorption are reduced and the compressive strength, wear, traction and elasticity modulus are increased.(17) In order to reduce the polymerization shrinkage, it was necessary to increase the percentage of inorganic particles of the composite resins, so it was reduced the particle size, which allows a better distribution of the inorganic particles.(18)

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The use of nanotechnology in composite resins allowed the size reduction of inorganic particles and allowed the reduction of the polymerization stress and increased resistance to wear.(19) In this study, Durafill® VS (microparticulate) resin presented the highest marginal microleakage scores, which may be caused by the presence of TEGDMA monomer in the organic matrix composition and a low percentage of inorganic particles volume. Factors that favor the occurrence of a high polymerization contraction.(5,7,15) The Charisma® Diamond composite resin presented the lowest rates of marginal microleakage. In their composition are the monomers UDMA and TCD-DI-HEA (bis- (acryloyloxymethyl) tricyclo [5.2.1.0.sup.2.6) decane. According to Suzuki et al.(20), the TCD-DI-HEA monomer provides low polymerization shrinkage, low viscosity and higher wear resistance. There was no statistically significant difference between Charisma® Opal (micro-hybrid) and Charisma® Diamond (nano-hybrid) resins (p>0.05). This result may be due to the similar amount of particle volume, being 58% and 64% respectively. Mahmud et al.(21) (2008) in a follow-up of 2 years verified a very acceptable clinical performance of the resins with nanotechnology being similar to a micro-hybrid resin. Further research involving marginal microleakage tests should be developed to increasingly explain the performance of composite resins in cavity preparations in order to promote the better longevity of restorative procedures.(13) Conclusions

According to the methodology used, it is concluded that:

- None of the composite resins were able to prevent marginal infiltration; - The nano-hybrid resin (Group 3 / Charisma® Diamond) had the lowest infiltration scores, and the microparticulate (Group 1 / Durafill® VS) had the highest scores; - In the comparison between the groups, it was verified that there was a statistically significant difference (p<0.05) between G1 x G2; G1 x G3 and that there was no difference between G2 x G3. References 1. Silva JMF, Rocha DM, Kimpara ET, Uemura ES. Resinas compostas: estágio atual e perspectivas. Revista Odonto. 2008; 16(32), 98-104. Avaliable from: https://www.metodista.br/revistas/revistas-ims/index.php/Odonto/article/view/560/558 2. Aimi E, Lopes GC. Restaurações Diretas de Resina Composta em Dentes Posteriores: uma Realidade no Brasil do Século XXI. Clínica – International Journal of Brazilian Dentristry. 2007; 3(1), 32-40. 3. Yamazaki PCV, Bedran-Russo AKB, Pereira PNP, Swift Junior EJ. Microleakage evaluatin of a new low-shrinkage composite restorative material. Oper Dent. 2006; 31(6), 670-76. Avaliable from: http://www.jopdentonline.org/doi/pdf/10.2341/05-129 4. Kamishima N, Ikeda T, San H. Color and translucency of resin composites for layering techniques. Dent Mater J. 2005; 24(3), 428-432. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/16279735 5. Anusavice KJ. Phillips Materiais Dentários. 11 ed. Elsevier: São Paulo; 2005. 6. Dewaele M, Boutry DT, Devaux J, Leloup G. Volume contraction in photocured dental resins: the shrinkage-cnversin relatinship resivited. Dent Mat. 2006; 22(1),

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359-365. Avaliable from: https://www.demajournal.com/article/S0109-5641(05)00185-5/pdf 7. Baig MM, Mustafa M, Jeaidi ZA, Al-Muhaiza M. Microleakage evaluation in restorations using different resin composite insertion techniques and liners in preparations with high c-factor – An in vitro study. King Saud University Journal of Dental Sciences. 2013; 4, 57-64. Avaliable from: https://core.ac.uk/download/pdf/82778635.pdf 8. Baratieri LN, Junior SM, Poletto LTAP, Vieira LCC. Restaurações com resina composta (classes V e III). In: Baratieri LN, Andrada MAC, Andrada RC, Andrade CA, Brandesburgo PC, Cardoso AC, et al. Dentística: procedimentos preventivos e restauradores. 2 ed. Santos: São Paulo: Santos; 2002. p. 201-211. 9. Nunes OBC, Abreu PH, Nunes NA, Portolani Junior MV, Berne CP. Infiltração marginal de resinas compostas associadas a sistemas adesivos com e sem carga. Rev Facul Odontol Lins. 2009; 21, 49-59. Avaliable from: https://www.metodista.br/revistas/revistas-unimep/index.php/Fol/article/view/69/26 10. Pinheiro SL, Aguiar JMRP, Adabo LH, Marchiori MB, Cancian NM, Lugli TG. Avaliação da microinfiltração da resina composta após acabamento com instrumento rotatório em diferentes períodos. Rev. Ciênc. Méd. 2010; 19(1-6), 5-12. Avaliable from: https://seer.sis.puccampinas.edu.br/seer/index.php/cienciasmedicas/article/view/824/804 11. Silva RC, Raggio DF, Imparato JCP. Avaliação da microinfiltração marginal de dois cimentos ionoméricos em dentes decíduos utilizados no tratamento restaurador atraumático. Rev Paul Odontologia. 2004; 26(2), 27-29. 12. Barbosa ECS, Cavalcanti AL, Nascimento ABL. Avaliação in vitro da microinfiltração em restaurações classe V em dentes decíduos utilizando diferentes resinas compostas. Revista da Faculdade de Odontologia. 2005; 10(2), 55-58. Avaliable from: http://seer.upf.br/index.php/rfo/article/view/1493/991 13. Ribeiro RA, Dantas DCRED, Ribeiro AIAM, Braz R, Lobo JS, Monteiro BVB, et al. Avaliação in vitro da microinfltração marginal em restaurações classe II utilizando diferentes técnicas de inserção de resina composta. Faculdade de Odontologia de Lins/Unimep. 2012; 22(1), 17-23. Avaliable from: https://www.metodista.br/revistas/revistasunimep/index.php/Fol/article/view/1192/945 14. Cavalcante LM, Schneider LFJ, Silva LS, Bedran-Russo AK, Pimenta LAF. Efeito da ciclagem térmica na microinfiltração e microtração de restaurações de resina composta. RFO. 2009; 14(2), 132-138. Avaliable from: http://files.bvs.br/upload/S/1413-4012/2009/v14n2/a132-138.pdf 15. Conceição, EN. Dentística Saúde e Estética. Artmed: Porto Alegre; 2007. 16. Gonçalves F, Kawano Y, Braga RR. Contraction stress related to composite inorganic content. Dent Mater. 2010; 26(7), 709-719. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/20378161 17. Kim KH, Ong JL, Okuno O. The effect of filler loading and morphology on the mechanical properties of contemporary composites. J Prosthet Dent. 2002; 87(6), 642-449. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/12131887 18. Mondelli J. Restaurações Estéticas. Sarvier: São Paulo; 1984. 19. Cramer NB, Stansbury JW, Bowman CN. Recent Advances and Developments in Composite Dental Restorative Materials. J Dent Res. 2011; 90(4), 402-416. Avaliable from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144137/pdf/10.1177_0022034510381263.pdf

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20. Suzuki T. Kyoizumi H. Finger WJ, Kanehira M, Endo T, Utterodt A, Hisamitsu H, Komatsu M. Resistance of nanofill and nanohybrid resin composites to toothbrush abrasion with calcium carbonate slurry. Dental Materials Journal. 2009; 28(6), 708-716. Avaliable from: https://www.jstage.jst.go.jp/article/dmj/28/6/28_6_708/_article 21. Mahmud SH, El-Embaby AE, AbdAllah AM, Hamama HH. Two year clinical evaluation of ormocer, nanohybrid and nanfil composite restorations systems posterior teeth. J Adhes Dent. 2008; 10(4), 315-322. Avaliable from: https://s3.amazonaws.com/academia.edu.documents/43144820/Two-year_clinical_evaluation_of_ormocer_20160227-9366-brwtqm.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1535333402&Signature=GTOVaYWrAhrGP2RkqI8c4QEwEVw%3D&response-content-disposition=inline%3B%20filename%3DTwo-year_clinical_evaluation_of_ormocer.pdf

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LINES OF RESEARCH IN DENTISTRY DEVELOPED IN A HIGHER EDUCATION INSTITUTION

LÍNEAS DE INVESTIGACIÓN EN ODONTOLOGÍA DESARROLLADAS EN UNA

INSTITUCIÓN DE ENSEÑANZA SUPERIOR

LINHAS DE PESQUISAS EM ODONTOLOGIA DESENVOLVIDAS EM UMA INSTITUIÇÃO DE ENSINO SUPERIOR

Maria Ângela Arêa Leão Ferraz1, Suyanne Rauanne Leal Bandeira2, Lara Line Nolêto Martins3, Mariana da Silva Corrêa Nolêto4, Moara e Silva Conceição Pinto5, Raony Môlim de Sousa Pereira6, Carlos Alberto Monteiro Falcão7 1 – Universidade Estadual do Piauí – UESPI, PhD in Endodontics. E-mail: angela.endo@hotmail.com 2 – Universidade Estadual do Piauí – UESPI, Dentist. E-mail: suyanne-rauanne@hotmail.com 3 – Universidade Estadual do Piauí – UESPI, Dentist. E-mail: lara_line@hotmail.com 4 – Universidade Estadual do Piauí – UESPI, Dentist. E-mail: mary_scn@hotmail.com 5 – Universidade Estadual do Piauí – UESPI, Dentist. E-mail: moara.c@hotmail.com 6 – Universidade Estadual do Piauí – UESPI, PhD in Oral Rehabilitation. E-mail: raonymolimsp@hotmail.com 7 – Universidade Estadual do Piauí – UESPI, PhD in Dental Clinics. E-mail: falcaoendo@hotmail.com

Maria Ângela Arêa Leão Ferraz (Corresponding author) PhD in Endodontics, Professor at Universidade Estadual do Piauí – UESPI, angela.endo@hotmail.com

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Abstract Objective: To evaluate the lines of scientific production developed by students of dentistry, that culminated in the end-of-course monograph work of a Higher Education Institution. Material and Method: Study with a quantitative approach, aiming to identify the areas studied that resulted in the production of end-of-course work in each Dentistry specialty, developed at the State University of Piauí – UESPI. Results: The specialties most studied by the students were Collective Health (24,39%), followed by Oral and Maxillofacial Surgery and Traumatology (13,82%) and Dentistry (9,43%); Dental Radiology and Imaging (0,4%) was the least researched; Education (1,62%), although not a specialty of Dentistry, also scored. Conclusion: The research lines of the UESPI Dentistry monograph works are predominantly of the disciplines present in the curricular matrix of the course. The most contemplated areas were Collective Health, Oral and Maxillofacial Surgery and Traumatology and Dentistry. Keywords: Dentistry; Education, Higher; Scientific Publication Indicators. Resumén Objetivo: Evaluar las líneas de producción científica desarrollada por académicos de Odontología que culminaron en los Trabajos de Conclusión de Curso (TCC) de una Institución de Enseñanza Superior. Material y Método: Estudio descriptivo, con abordaje cuantitativo, buscando la identificación de las áreas estudiadas que resultaron en la producción de los TCC en cada especialidad de la Odontología, desarrolladas en la Universidad Estadual del Piauí – UESPI. Resultados: Las especialidades más estudiadas por los graduandos fueron Salud Colectiva (24,39%), seguido por Cirugía y Traumatología Buco-Maxilo-Facial (CTBMF) (13,82%) y Dentística (9,43%); Radiología Odontológica e Imaginología (0,4%) fue la menos investigada; La educación (1,62%), aunque no es una especialidad de la Odontología, también puntuó. Conclusión: Las líneas de investigación de los TCC de Odontología de la UESPI son predominantemente de disciplinas presentes en la matriz curricular del curso. Las áreas más contempladas fueron Salud Colectiva, CTBMF y Dentística. Descriptores: Odontología; Educación Superior; Indicadores de Producción Científica. Resumo Objetivo: Avaliar as linhas de produção científica desenvolvidas por acadêmicos de Odontologia que culminaram nos Trabalhos de Conclusão de Curso (TCC) de uma Instituição de Ensino Superior. Material e Método: Estudo descritivo com abordagem quantitativa, buscando a identificação das áreas estudadas que resultaram na produção dos TCC em cada especialidade da Odontologia, desenvolvidas na Universidade Estadual do Piauí – UESPI. Resultados: A especialidades mais estudadas pelos graduandos foram Saúde Coletiva (24,39%), seguido por Cirurgia e Traumatologia Buco-Maxilo-Facial (CTBMF) (13,82%) e Dentística (9,43%); Radiologia Odontológica e Imaginologia (0,4%) foi a menos pesquisada; Educação (1,62%), embora não seja uma especialidade da Odontologia, também pontuou.

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Conclusão: As linhas de pesquisas dos TCC de Odontologia da UESPI são predominantemente de disciplinas presentes na matriz curricular do curso. As áreas mais contempladas foram Saúde Coletiva, CTBMF e Dentística. Descritores: Odontologia; Educação Superior; Indicadores de Produção Científica. Introduction Scientific research is fundamental to all areas of knowledge. This allows to confront data, empirical evidence and information on a certain subject with theoretical knowledge. The development of an area is commensurate with the need for further research for its steady progress. These function as "propelling springs" of knowledge in a given area, allowing the combination of new scientific knowledge with existing ones, either by improving or innovating it.(1-3)

During the academic formation, the development of a research project can contribute to the perspective of the student’s constant updating, through the search for new knowledge and critical analysis of the literature, positively impacting on their future professional life.(4-5)

To implement this conception in undergraduate courses in Dentistry, the National Curricular Guidelines and the General Guidelines for Undergraduate Courses, have as optional the mandatory or not the elaboration of a End-of-Course Monograph Work (usually called TCC in Brazil) that should be oriented by supervisors teachers, whose adaptations to curricula and courses will be the responsibility of each institution that so opts. The use of scientific methodology, since it is a question of research, works as a tool to solve problems, influencing creativity and continuation of studies.(5-7)

TCC is the moment in which the academic associates his area of affinity with the scientific production, developing the competences in the professional field and the abilities to understand specific questions to which it was studied during the graduation. TCC should be seen as a challenge or problem that seeks to arrive at a feasible solution or answer, and can be understood as beyond a simple academic discipline.(8-9) The valorization of TCC confirms the importance of scientific initiation for the improvement of the critical vision and refinement of the capacity to work under guidance and in group.(5)

Through these works can be noted the areas of research of undergraduates, as well as reveal how the university is training its professionals. In this way, analyzing the research topics of the TCC allows the institution to draw a panorama about the undergraduate course itself, the works produced and to know which areas of special interest of the graduates.(9-11)

Dentistry comprises 19 specialties described in the Consolidation of Norms for Procedures in the Dentistry Council approved by the Resolution of the Federal Council of Dentistry through resolution 063 of 2005, updated in July 2012 (Buco-Maxillofacial Surgery and Traumatology, Dentistry, Temporomandibular Dysfunction and Orofacial Pain, Endodontics, Stomatology, Dental Radiology and Imaging, Implantology, Dentistry, Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery - Acupuncture, Homeopathy and Sports Dentistry - recently authorized by the Federal Council of Dentistry through Resolution 160 of 2015.(12-13)

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Within this context, it is believed that it is pertinent to understand the connection between TCC and the thematic areas in which such work is carried out. This work consists of the mapping of the themes developed in the monographs of the Dentistry course of the State University of Piauí - UESPI, Campus Alexandre Alves Oliveira, Parnaíba, PI, Brazil.

Material and methods

The present research is a cross-sectional, descriptive observational study with a quantitative approach. It is characterized as transversal, because the factors under study are measured in a single moment, and observational descriptive, once it describes the occurrence of a situation without intervening on the object.

The analyzed data source refers to the monographs of the graduation course in Dentistry of UESPI between the years 2004 to 2016, totaling 246 monographs. Data were provided by the coordination database of this course.

Through the information provided, the titles and the corresponding competence specialty in dentistry were read. The collected data were organized in a spreadsheet for the tabulation of the pertinent elements to the study, for later to be carried out the descriptive analysis. Results

In a total of 22 specialties of Dentistry, it was observed that 16 of them were contemplated in the 246 works realized. There was a higher concentration of themes in the areas of Collective Health (24.39%), Buccomaxillofacial Surgery and Traumatology (13.82%), Dentistry (9.43%) and Endodontics (7.72%), totaling 50 % of work.

The remaining areas were: Pediatric Dentistry (7.72%) Periodontics (7.72%), Orthodontics (6.09%), Dentistry for patients with special needs (4.87%), Implantology Dental (2.84%), Oral Pathology (2.84%), Odontogeriatrics (2.84%), Legal Dentistry (1.62%), Work Dentistry (1.21%) and Dental Radiology and Imaging (0.40%). Complementary Therapies (0.81%) and Education, which is not part of dental specialties, was present in 1.62% of the works, as shown in Table 1.

Table 1 - Distribution of the subjects of TCC according to the dental specialties of the UESPI Dentistry course from 2004 to 2016.

SPECIALTIES n % Collective Health 60 24,39 Buco-Maxillo-Facial Surgery and Traumatology 34 13,82 Dentistry 23 9,43 Endodontics 19 7,72 Pediatric dentistry 19 7,72 Periodontics 19 7,72 Orthodontics 15 6,09 Dentistry for patients with special needs 12 4,87 Implantodontia 10 4,06 Dental prosthesis 7 2,84 Oral Pathology 7 2,84 Odontogeriatria 7 2,84

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Legal Dentistry 4 1,62 Education 4 1,62 Work Dentistry 3 1,21 Complementary Therapies 2 0,81 Dental Radiology and Imaging 1 0,40 Total 246 100%

Discussion

The alternative work for the conclusion of the course has required the institution's effort so that the work produced is not a mere academic exercise, but an aid in the decision-making of the area of future action and can be an indicator of institutional quality, with the possibility of contributing to resolutions of social problems, professional satisfaction and attention to the area of pleasure and skill.(14)

In agreement with Leite et al's(5) study, where preferences, which also totaled 50%, occurred respectively in the areas of Oral Pathology, Collective Health, Epidemiology and Bucomaxillofacial Surgery and Traumatology.

The UESPI Dentistry course is divided into 10 periods. An important factor to note is that among the four areas most sought after by the academics during the development of TCC are the first specific subjects, according to the curricular matrix of the course, being taught in the 5th and 6th periods. Other less frequently noted specialties, such as Pediatric Dentistry, Orthodontics and Implant Dentistry, are studied in subsequent periods.

It is understood that Public Health is the theme most explored because it represents the dimension of the professional needs of students, since the insertion of the labor market occurs through the Unified Health System, which was inserted as a learning scenario in the reorganization of the curriculum of dentistry.(15,16)

In addition, the specialties Stomatology, Tempomandibular Dysfunction and Orofacial Pain, Functional Jaw Orthopedics, Sports Dentistry, Acupuncture and Homeopathy, were not addressed in the TCCs. Note that of these, only Temporomandibular Dysfunction and Orofacial Pain is present in the curricular matrix of the course. It should be noted that the last three were recently recognized as specialties in Dentistry, through Resolution CFO-160/2015.

Conclusion The research lines of the UESPI Dentistry TCCs are mostly of the disciplines present in the curricular matrix of the course. The most contemplated areas were Collective Health, Bucomaxillofacial Surgery and Traumatology and Dentistry, which, together, corresponded to almost 50% of the total work. The less researched discipline was Dental Radiology and Imaging. Complementary Therapies and Education, even though they were not considered dental specialties, were also addressed. References 1. Barretto M. Produção científica na área de turismo. In: MOESCH, M. Um outro turismo é possível. São Paulo: Contexto, 2004, p. 83-93.

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2. Dencker AFM. Métodos e técnicas de pesquisa em turismo. 5 ed. São Paulo: Futura, 2001. 3. Rejowski M. Produção científica em turismo: análise de estudos referenciais no exterior e no Brasil. Rev. Turismo em Análise, São Paulo. 2010; 21(2), 224- 246. Avaliable from: http://www.revistas.usp.br/rta/article/view/14215/16033 4. Guedes HTV, Guedes JC. Avaliação pelos Estudantes, da Atividade “Trabalho de Conclusão de Curso” como Integralização do Eixo Curricular de Iniciação à Pesquisa Científica em um Curso de Medicina. Rev Bras Educ Med. 2012; 36(2),162-71. Avaliable from: http://www.scielo.br/pdf/rbem/v36n2/03.pdf 5. Leite BDF; Menêzes TB; Noro LRA. Análise Bibliométrica de Trabalhos de Conclusão de um Curso de Odontologia no Nordeste Brasileiro. Rev ABENO. 2015; 15(3),16-25. Avaliable from: https://revabeno.emnuvens.com.br/revabeno/article/view/172/170 6. Brasil. Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Parecer 146 de 2002; 90(10),1-69. 7. Heyden MST, Resck ZMR, Gradim CVC. A pesquisa na Graduação em Enfermagem: Requisito para Conclusão do Curso. Rev Bras Enferm. 2003; 56(4), 409-11. Avaliable from: http://www.scielo.br/pdf/reben/v56n4/a21v56n4.pdf 8. Oliveira NA. Áreas Temáticas de Pesquisa dos TCC’s do Curso de Bacharelado em Turismo da Universidade do Estado do Mato Grosso – Campus de Nova Xavantina. RTEP/UERN. 2013; 2(2), 37-65. Avaliable from: http://periodicos.uern.br/index.php/turismo/article/view/849/458 9. Trigo LGG. A sociedade pós-industrial e o profissional em turismo. Campinas: Papirus, 1998. 10. Ansarah MG dos R. Formação e capacitação do profissional em turismo e hotelaria: reflexões e cadastro das instituições educacionais no Brasil. São Paulo: Aleph, 2002. 11. Novaes MH. Trabalho de conclusão de curso (TCC). In: ANSARAH, Marília (org.). Turismo: como aprender, como ensinar, 2. 3 ed. São Paulo: SENAC, 2004, p. 375-390. 12. Brasil. Resolução do Conselho Federal de número 063 de 2005. Consolidação das Normas para Procedimentos no Conselho de Odontologia. Conselho Regional de Odontologia. 19 de abril de 2005. 13. Brasil. Resolução do Conselho Federal de número 160 de 2015. Reconhece a Acupuntura, a Homeopatia e a Odontologia do Esporte como especialidades odontológicas. Conselho Regional de Odontologia. 02 de outubro de 2015. 14. Saupe R, Wendhausen ALP, Machado HB. Modelo para a implantação ou revitalização dos trabalhos de conclusão de curso. Rev. Latino–am Enfermagem. 2004; 12(1), 109-14. Avaliable from: http://www.scielo.br/pdf/rlae/v12n1/v12n1a15.pdf 15. Pinheiro VC, Menezes LMBD, Aguiar ASWD, Moura WVBD, Almeida MELD, Pinheiro FMDC. Inserção dos egressos do curso de Odontologia no mercado de trabalho. Rev Gaúcha Odontol, Porto Alegre. 2011; 59(2), 277-283. Avaliable from: http://revodonto.bvsalud.org/pdf/rgo/v59n2/a16v59n2.pdf 16. Silveira JLGC, Garcia VL. Mudança curricular em Odontologia: significados a partir dos sujeitos da aprendizagem. Rev Interface. 2015; 19(52), 145-58. Avaliable from: https://www.scielosp.org/pdf/icse/2015.v19n52/145-158/pt

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SYSTEMIC CHANGES AND THEIR RELATIONS IN THE PLANNING OF ENDODONTICAL TREATMENT

ALTERACIONES SISTÉMICAS Y SUS RELACIONES EN LA PLANIFICACIÓN DEL

TRATAMIENTO ENDODÓNTICO

ALTERAÇÕES SISTÊMICAS E SUAS RELAÇÕES NO PLANEJAMENTO DO TRATAMENTO ENDODÔNTICO

Ilberto Pereira da Silva Júnior1, Karen Kimberlly Pinto Lacerda2,Claúdia Fernanda Caland Brígido3, Carlos Alberto Monteiro Falcão4, Rogério Barbosa Batista de Moura5,Tanit Clementino Santos6

1 – Centro Universitário UNINOVAFAPI, Graduation in Dentistry, Teresina, PI, Brazil; E-mail: ilberto2015@outlook.com 2 – Centro Universitário UNINOVAFAPI, Graduation in Dentistry, Teresina, PI, Brazil; E-mail: karenkimber11y@hotmail.com 3 – Centro Universitário UNINOVAFAPI, PhD in Biotechnology, Teresina, PI, Brazil. E-mail: cbrigido@uninovafapi.edu.br 4 – Centro Universitário UNINOVAFAPI, PhD in Dental Clinics, São Leopoldo Mandic –SP, Brazil. E-mail: falcaoendo@hotmail.com 5– Centro Universitário UNINOVAFAPI, Specialist in Implant Dentistry and Dental Prosthesis, NINGÁ-PR, Brazil. E-mail: rogerbbmoura@hotmail.com 6– Centro Universitário UNINOVAFAPI, PhD in Dentistry (Endodontics) from the Universidade de Ribeirão Preto, Brazil. E-mail: tsantos@uninovafapi.edu.br

Carlos Alberto Monteiro Falcão (Corresponding author) PhD in Dental Clinics, Professor at Universidade Estadual do Piauí – UESPI, falcaoendo@hotmail.com

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Abstract Objective: To evaluate the knowledge of dental academics about the systemic alterations that influence the planning of endodontic treatment. Material and Method: Exploratory, descriptive study of a quantitative approach with 175 undergraduate students in the Dentistry of a Teaching Institution. Interviews were conducted through questionnaires. Results: The following resources were used in the diagnosis of pulp alterations: anamnesis, periapical Rx, vitality test and vertical percussion. Regarding the medical history, 95.18% performed the complete endodontic survey. Related to systemic diseases, the importance of 100% was verified, how to assess severity through medical history, routinely check blood pressure, know the medication in use, control the patient's anxiety, consult the patient's physician, use of anesthetic and the need for antibiotic prophylaxis. Conclusion: We conclude that there is a superficial knowledge about systemic diseases and endodontic treatment. Keywords: Endodontic; Planning; Knowledge. Resumen Objetivo: Evaluar el conocimiento de los académicos de odontología acerca de las alteraciones sistémicas que influencian en la planificación del tratamiento endodóntico. Material y método: Estudio exploratorio, descriptivo de abordaje cuantitativo con 175 académicos del curso de graduación en Odontología de una Institución de Enseñanza. Se realizaron entrevistas a través de cuestionarios. Resultados: Se verificó en 100% en el diagnóstico de las alteraciones pulpares la utilización de los siguientes recursos: anamnesis, Rx periapical, prueba de vitalidad y percusión vertical. Relacionados al historial médico 95,18% realizaron el levantamiento completo para endodoncia. En cuanto a las enfermedades sistémicas, se verificó la importancia del 100%, como evaluar la gravedad por medio del historial médico, medir la presión arterial rutinariamente, conocer la medicación en uso, control de la ansiedad del paciente, consultar al médico del paciente, el anestésico apropiado y la necesidad de profilaxis antibiótica. Conclusión: Se concluye que existe un conocimiento superficial sobre las enfermedades sistémicas y el tratamiento endodóntico. Palabras-Clave: Endodoncia; Planificación; Conocimiento. Resumo Objetivo:Avaliar o conhecimento dos acadêmicos de odontologia acerca das alterações sistêmicas que influenciam no planejamento do tratamento endodôntico. Material e Método: Estudo exploratório, descritivo de abordagem quantitativa com 175 acadêmicos do curso de graduação em Odontologia de uma Instituição de Ensino. Foram realizadas entrevistas por meio de questionários. Resultados: Verificou-se em 100% no diagnóstico das alterações pulpares a utilização dos seguintes recursos: anamnese, Rx periapical, teste de vitalidade e percussão vertical. Relacionados ao histórico médico 95,18% realizaram o levantamento completo para endodôntia. Relacionado às doenças sistêmicas, verifiou-se a importância de 100%, quanto avaliar a gravidade por meio do histórico médico, aferir a pressão arterial rotineiramente, conhecer a medicação em uso, controle da ansiedade do paciente, consultar o médico do paciente, utilização de anestésico apropriado e necessidade de profilaxia antibiótica.

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Conclusão: Conclui-se que existe um conhecimento superficial sobre as doenças sistêmicas e o tratamento endodôntico. Descritores: Endodontia; Planejamento; Conhecimento. Introduction

With the growth of the expectation and improvement in the quality of life, the population has increased the demand for specialized dental care. This constant fact requires a primary attention of dental surgeons, as they have been faced with increasingly differentiated patients in search of treatments that aim to improve them oral health.(1)

With increasing population longevity, the systemic and chronic diseases associated with the use of multiple constant medications, show a tendency to grow. This fact also highlights the need for dental surgeons to be more prepared for care and a detailed clinical examination in this specific public.(2)

According to the observation of the general state of the patient that should be considered, we have the conditions of the dental element, with special attention to the radiographic interpretation; the technique employed and the operator's ability, which can lead to inadequate access, perforations, fracture of instruments, over fillings and incomplete fillings, amongst others.(3-5)

Regarding endodontic therapy, it can be described as the maintenance of the tooth in the buccal cavity in function, without harm to the health of the patient. Endodontic treatment should follow scientific and biological principles to reduce the chances of failure and accidents, considering the particularities of each patient.

The microbiological factor has been highlighted in the specialized literature, and most pulp and periapical diseases are directly or indirectly related to the development of microorganisms.(3-5)

Luckmann et al.(6) also reported on the microbiological factor, in which they point to this as the main cause of failure of endodontic treatment. The percentage of cases of failure is expressive, and the areas were not reached during the chemical-surgical preparation are favorable to the maintenance of septic-necrotic content, which contributes directly to the failure of therapy.

The collection of scientific data is not sufficient to formulate an accurate clinical diagnosis. The facts should be collected through an active dialogue between the clinician and the patient. In essence, the process of determining the existence of a pathological pathological process results from the art and science of performing an accurate diagnosis.(7) However, this apparently difficult conception of diagnosis is mitigated by the possibility of using auxiliary resources that, in company with the professional's ability and ability, lead correctly and coherently to the treatment.(8)

The clinician should evaluate the patient's response to the health questionnaire from two perspectives: systemic conditions or medications in use that will need to change the way in which the dental treatment to be performed. Although most systemic changes do not contraindicate endodontic treatment, they may influence the course of treatment and require specific modifications, such as: age, infectious diseases, endocrine-metabolic degeneration, cardiovascular diseases, diabetes, cancer, among others etc.(9)

Considering that the possibility of the dental professional facing a patient with one of these systemic alterations is enormous, the CD should present a greater responsibility during the treatment of a patient with medical problems. And for this, a

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good professional should be able to carry out a good anamnesis, including medical history.(2)

In addition, observations regarding patients should be placed in the dental chart, which is one of the most important documents produced by dental surgeons, as they record several types of daily dental procedures performed during the treatment of a patient and the particularities they present each of their patients.(10)

For this set of reasons is that the knowledge about the procedures to be performed in the treatments are of fundamental importance. It can also be added that this knowledge is not always part of the domain of professionals and students who practice dentistry, which can lead to the choice of inadequate treatment plans and, consequently, the occurrence of severe damage to the health conditions and the maintenance of the elements in the oral cavity.(11)

In view of the above, the object of this study was the knowledge of the academics about the systemic alterations and their implication in the planning of an endodontic treatment and presented as guiding questions: "What is the knowledge of dentistry academics about systemic alterations?" And "What is the implication of systemic diseases in the planning of endodontic treatment?"

The objective of the present study was to evaluate the knowledge of dentists about the systemic alterations that influence the planning of endodontic treatment. Materials and Method

This is a descriptive study of a quantitative approach, carried out in the city of Teresina - Piauí, at the Integrated Health Center (CIS) of the Centro Universitário UNINOVAFAPI.(12-13)

A total of 175 students from the dentistry course participated in the study. The following inclusion criteria were chosen: to be enrolled regularly, attending courses after the 5th Period, and have already studied the subjects related to endodontics, semiology and diagnosis and are in routine activities in the clinic.

To represent the population surveyed, a sample survey was performed using a sample of 176 students. This sample was calculated as follows:

n= (1,96)2x [0,50 x 0,50]/(0,055)2 = 317, at where,

1.96 is the normal curve score for the 95% confidence level

0.50 is the hypothetical value of the study parameter so as to generate a maximum variance;

0.50 = 1 - p is the complementary value of the parameter;

0,055 is the margin of error expressed in proportion. Since it is a finite population of 391 students, the original sample size can be

resized to:

n=317 / 1 + (317 / 391) = 175. Sampling was probabilistic of stratified type with proportional distribution

whose stratification criterion was the period that the student was enrolled. The names of the students enrolled in each period were enumerated for drawing the sample determined in each stratum. This draw was carried out by the program BiosEsta 2.0.

Data collection was performed through a structured questionnaire with closed and open questions. The content of the questionnaire ranges from sociodemographic information (age, gender, period) to the variables on the proposed topic, namely: tests used for the diagnosis of pulp alterations; habit of raising the patient's medical history; habit to check the patient's blood pressure and pulse before the consultation and the ET; experience with cases of reaction to anesthetics and attitude towards the

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situation; types of care with hypertensive patients submitted to ET; attitudes towards patients with myocardial infarction with indication of ET; care of diabetic patients in the implementation of ET; care with patients diagnosed with CA of mouth with indication of ET and pregnant patients.

The questionnaires were applied through face-to-face face-to-face interviews conducted by the authors of the research after the acceptance and signing of the Informed Consent Term (TCLE).

We initially worked with a Microsoft Excel for Windows spreadsheet that was exported to the IBM SPSS Statistics 20. The statistical analysis was descriptive using test X2 (chi-square) with an alpha significance level of 5%.

The research was approved by the Research Ethics Committee (CEP) of the University Center UNINOVAFAPI, with the approval number of CAEE nº 50149215.6.0000.5210. The ethical requirements have been respected. All participants signed the ICF. Results

The results of the tests that were routinely used in the clinic to assess the pulp alterations (86.14%) of the participants evaluated RxPeriapical, followed by vitality test (84.94%), anamnesis test (60.84%) and vertical percussion (51.81%) as routine tests to detect pulpal changes. In the initial periods (6th, 7th and 8th) the examinations were evaluated in the following order: Rxperiapical, vitality test, anamnesis and vertical percussion; in the final periods (9th and 10th) the exam choices were in the following order: Vitality test, Rxperiapical, Vertical Percussion and Anamnesis.

In addition, (95.18%) of the students reported performing a complete medical history survey of patients for Endodontic Treatment routinely. Regarding the achievement of blood pressure measurement and pulse check before endodontic treatment, (84.94%) of the participants mentioned not performing this clinical procedure, while (15.06%) stated that they performed.

Regarding the care they should have in performing an Endodontic Treatment in hypertensive patients, (89.16%) of the students chose as a priority to assess the severity of hypertension through medical history, followed by (78.31%) blood pressure measurement at (72.29%) knowledge about the medication in use, (50.60%) control the patient's anxiety, (46.39%) consult the patient's doctor about their problems and (40.96%) use anesthetic without vasoconstrictor. A uniformity of responses was observed regardless of period.

Regarding the care of infarcted patients (6 to 12 months before dental treatment) with indication for Endodontic Treatment, (76.56%) of the students prioritized consulting the patient's physician before any dental treatment, followed by blood pressure measurement use antibiotic prophylaxis (48.19%), use anesthetic without vasoconstrictor (36.14%) and make short consultations, preferably in the morning (32.56%). There was a concern of the students about consulting the patient's physician and the care in checking the blood pressure at each visit.

Regarding the care of diabetic (compensated) patients with indications for Endodontic Treatment, (84.94%) prioritized observing the systemic situation (compensated or not) through the exams; (69.29%) to know the type of diabetes, reduce the risk of infection (61.45%), preferential care (morning) 53.61%, medication used by the patient (52.41%), each consultation (30.72%). A concern of the students regarding the history and medical diagnosis of the patient was observed (6,7,8), and

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the 9 and 10 periods prioritized the care in attending the patient (preferential care in the morning) and knowing their detailed medical history.

Regarding the care of patients who had mouth cancer and who had indication for Endodontic Treatment, (87.95%) prioritized to know all the treatment performed by the patient (surgical, chemotherapeutic, radiotherapeutic, immunotherapeutic), as well as the current treatment situation ; (83.73%) to perform a good anamnesis, clinical examination and complementary exams; (73.49%) reduce the risk of infection; (47.59%) avoid delayed ET sessions and avoid bloody procedures. A consistent trend was observed in students' responses from the 6th to the 10th period in prioritizing medical history and complete clinical examination, followed by reduced risk of infection, avoiding lengthy sessions, bloody procedures, and preferential care.

Discussion

The beginning of the treatment of a patient involves the knowledge of the

same from a detailed anamnesis and physical examination. For this, it is necessary for the Dentist to assume a commitment and responsibility to seek useful information, both for the diagnosis of disorders and for detecting previous dental experiences. Once a condition or systemic illness is observed, the professional should direct the evaluation, identifying the peculiarities that can interfere in the treatment. The research of the clinical signs and symptoms of the disease complements the anamnesis and thus helps in the determination of the diagnosis.(14)

A successful endodontic treatment plan depends on a correct diagnosis. In the alterations of the human dental pulp, the necessary reports for the establishment of its pathological conditions are restricted to anamnesis, clinical examination, pulp sensitivity tests and radiographic evaluation. This is due to the fact that the pulp is surrounded by dentin walls, a fact that prevents its direct visualization by the professional during clinical care.(15)

According to Ruiz(16), the clinical examination includes the objective data collected by the professional through examinations such as palpation, percussion, inspection and exploration. The palpation, from the touch and compression or digital grip, provides impressions about a certain area and can define shape, limits, consistency, texture, thickness, sensitivity, volume, mobility, content, fluctuation, temperature and elasticity modifications.

Estrela(17) stated that the inspection includes visual observation, physical inspection and extra and intraoral examination of soft tissues, which determine several aspects of the tissue conditions and conditions of the dental structures, constituting in fundamental aspects to be analyzed, as well as as the exploration is a sequence of inspection, in which the presence of dental cavities, periodontal pockets, fistulous trajectories, coronary and root fractures are observed.

The percussion test does not indicate the integrity of the pulp tissue, but it is important to evaluate the degree of periapical tissue involvement and if there is inflammation in the periodontal tissue, thus helping to diagnose periapical and / or periodontal pathologies. of vertical or horizontal dental percussion, respectively. Pulp vitality (sensitivity) tests are used as a supplementary physical examination to establish a differential diagnosis of odontalgias and to evaluate the vitality or otherwise of the pulp in various circumstances. Despite providing subjective answers, they are a great resource in determining a correct diagnosis.(16)

Among the commonly used tests, those performed by means of thermal stimulation (cold and heat) of the surface of the tooth to be investigated. In addition to

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easy execution, they are reliable and have a low cost to perform and also allow the determination of the irreversibility state of the pulp.(18) The most widely accepted test for determination of pulp vitality is the one performed by cooling the dental surface, and there are different ways of producing such an effect, such as the use of ice, carbon dioxide and refrigerant gases.(19)

Pain produced by thermal stimuli, heat or cold, is one of the most common symptoms present in cases of pulpitis. When there is reversible pulpal involvement, the painful response to cold is more intense, disappearing as soon as the stimulus is removed. In the possibility of responding positively to the test performed with heat and pain remaining after removal of the stimulus, the pulp is irreversibly inflamed. If there is no response, necrosis may be present.

Radiographic examination, when properly associated with the clinical examination of the patient, assists in locating and identifying the problem reported by the patient, thus obtaining the diagnosis and orientation for proper planning and treatment.(7)

It is of fundamental importance that the student of dentistry as well as the dental surgeons have knowledge of semiology and histopathology of the dentinopulpar complex, since, the elaboration of the most accurate diagnosis, consequently, will allow to indicate a correct treatment plan for each one of the pathological alterations pulpares. In addition, it is essential in clinical practice in dentistry courses a constant supervision of teachers to resolve the possibility of errors in diagnosis or even in the clinical conduct of the treatment by the academics, because they are in the process of professional training and consequently under the direct responsibility of a faculty.(20)

The collection of scientific data is not sufficient to formulate an accurate clinical diagnosis. The data must be interpreted and processed in order to determine which information is significant and which should be questioned. Therefore, a planned, systematic and methodical approach to this investigative process is crucial. The professional is responsible for raising the appropriate medical history of any patient who presents for treatment.(7)

According to Leonardo,(21) the anamnesis is an interrogation carried out on the patient, in order to allow the professional the clinical history of the case. In Endodontics, the main complaint is usually the pain. Thus, knowledge of the most diverse areas is necessary to determine a correct diagnosis.

Hypertension is a heart disease characterized by abnormal elevation of blood pressure. If there is no control, the patient may present serious complications, such as cerebrovascular accidents, kidney problems and thrombosis, which makes it an important public health problem in Brazil and in the world.(22)

For dentists, it is extremely important to be aware of the consequences and possible complications that may arise during clinical care or, as a result of the established drug therapy. The use of antihypertensives may cause some oral complications, such as decreased salivary secretion and increased gingival tissue - gingival hyperplasia associated with medication.(23)

Another factor that deserves to be emphasized and should be taken into account in the management of patients with hypertension is the use of local anesthetics (with or without vasoconstrictors), since their misuse can aggravate the patient's hypertension.(22)

Dentists usually find it difficult to treat hypertensive patients, because they fear the use of local anesthetics with vasoconstrictors and the drug interactions that may occur with antihypertensives.(24)

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The patient with cardiovascular impairment should be thoroughly evaluated. For the dental surgeon, a detailed history of patients with a history of angina pectoris, cardiac prostheses, myocardial infarction, heart failure and arrhythmias is important.(25)

Among cancer patients, the side effects of radiation therapy are: xerostomia, radiation caries, mucositis, osteoradionecrosis (ORN), dysphagia, loss or alteration of taste, opportunistic infections, periodontitis and trismus.(26-27)

Most patients have poor oral conditions, advanced periodontal disease, poorly fitting prostheses, and conditions associated with neglect of oral hygiene. Both inadequate oral hygiene and pre-existing dental diseases are the most common oral risk factors for oral complications arising from cancer treatment.(28)

The dental surgeon has a huge responsibility in eliminating local traumatic factors, in recognizing cancerous lesions, in guiding the reduction of exposure to environmental carcinogenic factors and in the early diagnosis of oral neoplasias, in the treatment and preservation of the patient, patient a better quality of life. Conclusion

He verified that the academics know the main systemic alterations that are

hypertension, cardiopathies, diabetes, and oral cancer, however they present discomfort and insecurity to the care of this patient. They understand that in order to objectify prevention and avoid an emergency situation, it is necessary to obtain of a good anamnesis of the patient and know the necessary measures to be adopted.

Given the above, it is essential in clinical practice in the Dentistry courses a constant supervision of the teachers to resolve the possibility of errors in diagnosis or even in the clinical conduct of the treatment by the academic, as well as, the establishment of clinical protocols to care for the carriers of systemic diseases, for possible reduction of errors in the academic and professional life of the dental surgeon.

References 1. Santos CC, Noro-Filho GA, Caputo BV, Souza RC, Andrade DMR, Giovani EM. Condutas práticas e efetivas recomendadas ao cirurgião dentista no tratamento pré, trans e pós do câncer. J Health Sci Inst. 2013; 31(4), 368-72.Avaliable from: https://www.unip.br/presencial/comunicacao/publicacoes/ics/edicoes/2013/04_out-dez/V31_n4_2013_p368-372.pdf 2. Kreuger MRO, Diegoli NM, Pedrini RDA, Porfírio VR, Silva F. Consulta odontológica e doença sistêmica: análise do conhecimento dos cirurgiões-dentistas em Itajaí-SC. Revista da Faculdade de Odontologia de Lins. 2009; 21(2), 15-22. Avaliable from: https://www.metodista.br/revistas/revistas-unimep/index.php/Fol/article/view/381/476 3. Nair PNR, Henry S, Cano V, Vera J. Microbial status of apical root canal system of human mandibular first molars with primary apical periodontitis after “one-visit” endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005; 99(2), 231-252. Avaliable from: https://www.sciencedirect.com/science/article/pii/S1079210404006821 4. Shabahang S. State of the Art and Science of Endodontics. J Am Dent Assoc. 2005; 136(1), 41-52. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/15693495

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5. Siqueira Jr JF, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J. Endod. 2008; 34(11), 1291-301. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/18928835 6. Luckmann G, Dorneles LC, Grando CP. Etiologia dos insucessos dos tratamentos endodônticos. Vivências. 2013; 9(16), 133-139. Avaliable from: http://www.reitoria.uri.br/~vivencias/Numero_016/artigos/pdf/Artigo_14.pdf 7. Cohen S, Hargreaves KM. Caminhos da Polpa. 9. ed. Elsevier Editora Ltda: Rio de Janeiro, 2008. 1079p. 8. Santos RMT. Desafios e Importância no Diagnóstico do Tratamento Endodôntico Não Cirúrgico. Tese de mestrado. Universidade Fernando Pessoa. Porto, Portugal. 2013. Avaliable from: http://bdigital.ufp.pt/bitstream/10284/5070/1/PPG_17967.pdf 9. Rosenberg PA, Schindler WG, Krell KV, Hicks ML, Davis SB. Identify the endodontic treatment modalities. J Endod. 2009; 35(12), 1675-1694. Avalible from: https://www.sciencedirect.com/science/article/pii/S0099239909007882 10. Silva RF. Importância ético-legal e significado das assinaturas do paciente no prontuário odontológico. RBOL. 2016; 3(1), 70-83. Avaliablefrom: http://portalabol.com.br/rbol/index.php/RBOL/article/view/49/53 11. Ribeiro ILA, Melo RTC, Trigueiro DA, Ferreira GS. Conduta clínica de cirurgiões-dentistas de João Pessoa-PB no tratamento endodôntico de dentes com rizogênese incompleta. Rev. Odontol. Univ. Cid. São Paulo. 2017; 26(3), 212-218. Avaliable from: http://publicacoes.unicid.edu.br/index.php/revistadaodontologia/article/view/304/201 12. Sousa LRM, Mesquita RF, Matos FRN, Moura LKB, Moura MEB. Dimensões da satisfação dos usuários da Estratégia Saúde da Família. Revista Portuguesa de Investigação Comportamental e Social. 2017, 3(2), 2-9. Avaliablefrom: https://dialnet.unirioja.es/servlet/articulo?codigo=6126343 13. Moura LKB, Mesquita RF, Mobin M, Matos FTC, Monte TL, Lago EC, et al. Uses of Bibliometric Techniques in Public Health Research. Iranian Journal of Public Health. 2017; 46(10), 1435-6. Avaliable from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750357/ 14. Campos CDC, Frazão BB, Saddi GL, Morais LA, Ferreira MG, Setúbal PCO, et al. Manual prático para o atendimento odontológico de pacientes com necessidades especiais. Goiânia: Universidade Federal de Goiás-Faculdade de Odontologia. 2009; 26-29. Avaliablefrom: http://www.abodontopediatria.org.br/Manual_para_atendimento_de_PNE.pdf 15. Silva AM, Santos CC, Reggiori MG, Andia-Merlin RM, Martins RB, Alegretti CE. Study of emotional and psychological factors that may interfere in the dental treatment.J. Health Sci. Inst. 2009; 27(3), 249-53. Avaliable from: http://files.bvs.br/upload/S/0104-1894/2009/v27n3/a015.pdf 16. Ruiz PA. Semiologia endodôntica. 2008. Avaliable from: http://www.endodontia.org/academica.htm 17. Estrela C. Estruturação do diagnóstico endodôntico. In: Estrela C. Ciência endodôntica. São Paulo: Artes Médicas; 2004. 18. Haddad Filho MS, Caldeira CL, Medeiros JMF.Confiabilidade do gelo e tetrafluoroetanoemdentes com pulpiteirreversível. Rev Assoc Bras Odontol.2009; 17(3), 165-71. 19. Medeiros JMF, Pinto CA, Rosa LCL, Habitante SM, Almeida ETDC, Zollner NA. (2017). Avaliação da escolha dos testes de sensibilidade pulpar por clínicos gerais da cidade de Taubaté. Revista de Odontologia da Universidade Cidade de São Paulo. 2010; 22(1), 30-38. Avaliablefrom:

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http://publicacoes.unicid.edu.br/index.php/revistadaodontologia/article/view/394/289 20. Santos KSA, Veloso OLL, Temóteo LM, Brito LNS. Degree of diagnostic agreement in Endodontics in dental clinics. RGO: RevistaGaúcha de Odontologia. 2011; 59(3).Avaliable from: http://revodonto.bvsalud.org/pdf/rgo/v59n3/a03v59n3.pdf 21. Leonardo MR. Endodontia: conceitos biológicos e recursos tecnológicos. São Paulo: Artes Médicas; 2009. 22. Oliveira AEMD, Simone JL, Ribeiro RA. Pacientes hipertensos e a anestesia na Odontologia: devemos utilizar anestésicos locais associados ou não com vasoconstritores. HU Revista. 2010; 36(1), 69-75. Avaliable from: http://www.gruponitro.com.br/atendimento-a-profissionais/%23/pdfs/artigos/anestesicos_locais/pacientes_hipertensos_e_a_anestesia.pdf 23. Yagiela JA, Haymore TL. Management of the hypertensive dental patient.CDA J. 2007; 35(1), 51-9.Avaliable from: https://europepmc.org/abstract/med/17269288 24. Carvalho, V. A. P., Borgatto, A. F., & Lopes, L. C. (2010). Nível de conhecimento dos cirurgiões-dentistas de São José dos Campos sobre o uso de anti-inflamatórios não esteróides. Ciência & Saúde Coletiva. 2010; 15 (Suppl), 1773-82. Avaliablefrom: https://www.scielosp.org/pdf/csc/2010.v15suppl1/1773-1782 25. Rhodus NL, Little JW. Dental management of the patient with cardiac arrhythmias: an update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 96(6), 659-668. Avaliable from: https://suffolkrootcanal.co.uk/wp-content/uploads/2015/04/Dental-management-of-the-patient-with-cardiac-arrhythmias-Rhodus-2003.pdf 26. Rapidis AD, Gullane P, Langdon JD, Lefebvre JL, Scully C, Shah JP. Major advances in the knowledge and understanding of the epidemiology, aetiopathogenesis, diagnosis, management and prognosis of oral cancer.Oral oncol. 2009; 45(4), 299-300. 27. Scully C. Oral squamous cell carcinoma; from an hypothesis about a virus, to concern about possible sexual transmission. Oral oncol. 2002; 38(3), 227-234. Avaliable from: https://www.sciencedirect.com/science/article/pii/S1368837501000987 28. Joshi VK. Dental treatment planning and management for the mouth cancer patient.Oral oncol. 2010; 46(6), 475-479. Avaliable from: https://www.sciencedirect.com/science/article/pii/S1368837510000990

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TOOTH SYNDROME CRACKED IN UPPER MOLAR RESTORED: CASE REPORT

SÍNDROME DEL DIENTE AGRIETADO EM MOLAR SUPERIOR RESTAURADO: RELATO DE CASO

SÍNDROME DO DENTE RACHADO EM MOLAR SUPERIOR RESTAURADO:

RELATO DE CASO Izadora Gabrielle Carvalho Borges1,Carlos Alberto Monteiro Falcão2, Maria Ângela Arêa Leão Ferraz3, Lucas Fernandes Falcão4

1 – Universidade Federal do Piauí. Specialist in Endodontics by the Center for Post-Graduation in Dentistry Pós-Doc. E-mail: izadora_borges_@hotmail.com 2 – Universidade Estadual do Piauí – UESPI, PhD in Dental Clinics. E-mail: falcaoendo@hotmail.com 3 – Universidade Estadual do Piauí – UESPI, PhD in Endodontics. E-mail: angela.endo@hotmail.com 4 – São Leopoldo Mandic, Master in Endodontics. E-mail: falcaoendo@hotmail.com

Izadora Gabrielle Carvalho Borges (Corresponding author) Specialist in Endodontics by the Center for Post-Graduation in Dentistry Pós-Doc izadora_borges_@hotmail.com

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Abstract Objective: The present study aims to present, through a clinical case, the importance of the early diagnosis and the treatment instituted in a tooth that presents a crack. Case report: Patient sought endodontic treatment due to an acute pain that felt in tooth 17. It had a restoration of amalgam in the occlusal without infiltration or without any clinically visible fracture. In the tests of palpation and percussion there was the presence of painful symptomatology and in the thermal test intense pain that took a few seconds to cease. Radiographically no periapical lesion was observed. After removal of the restoration, it was observed that the tooth presented a mesial to distal crack. The adopted treatment was the accomplishment of the endodontic treatment and subsequent prosthetic rehabilitation. Conclusion: Thus, it was concluded that teeth, when well diagnosed, can be treated and kept in the oral cavity. Keywords: Cracked Tooth Syndrome; Endodontics; Molar; Toothache.

Resumen Objetivo: El presente trabajotiene como objetivo presentar a través de un caso clínico, laimportanciadel diagnóstico precoz y eltratamientoinstituidoenundiente que presenta trinca. Relato de caso: El paciente buscótratamientoendodónticodebido a undolor agudo que sentíaeneldiente 17. El mismopresentaba una restauración de amalgama enlaoclusalsininfiltración o sinfracturaalgunavisibleclínicamente. Enlaspruebas de palpación y de percusiónhubola presencia de sintomatología dolorosa y eneltest térmico dolor intenso que tardóalgunos segundos para cesar. No se observó presencia de lesiónperiapical. Después de laremoción de larestauración se observó que eldientepresentabauntrío de mesial a distal. La conducta de tratamiento adoptado fuelarealizacióndeltratamientoendodóntico y posterior rehabilitación protética. Conclusión: Así se concluyó que dientes trincados, cuandobien diagnosticados, pueden ser tratados y mantenidosenlacavidad oral. Palabras-claves: Síndrome de DienteFisurado; Endodoncia; Diente Molar, Odontalgia. Resumo Objetivo:O presente trabalho objetiva apresentar através de um caso clínico, a importância do diagnóstico precoce e o tratamento instituído em um dente que apresenta trinca. Relato de caso:Paciente procurou tratamento endodôntico devido uma dor aguda que sentia no dente 17. O mesmo apresentava uma restauração de amálgama na oclusal sem infiltração ou sem fratura nenhuma visível clinicamente. Nos testes de palpação e de percussão houve a presença de sintomatologia dolorosa e no teste térmico dor intensa que demorou alguns segundos para cessar. Radiograficamente não foi observado presença de lesão periapical. Após a remoção da restauração observou-se que o dente apresentava uma trinca de mesial para distal. A conduta de tratamento adotada foi a realização do tratamento endodôntico e posterior reabilitação protética. Conclusão:Assim concluiu-se que dentes trincados, quando bem diagnosticados, podem ser tratados e mantidos na cavidade oral. Descritores: Síndrome de dente quebrado; Endodontia;Dente Molar;Odontalgia.

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Introduction Caries and periodontal disease are the main factors that cause tooth loss.

However, it is important to remember that studies show that a growing number of patients have been compromised by fractures,(1) which has become the third most common cause of tooth loss in industrialized countries.(2) These fractures may be related to a visible crack that can reach restored teeth or even healthy teeth.

The term cracked tooth syndrome was first described in 1964 in a paper by Cameron(3) and was defined as a crack or crack in the enamel and/or dentin in a vital posterior tooth, which occasionally extends to pulp. This fracture promotes the rupture of the tooth, but the segments do not separate, being held together by a portion of the dental structure(4), so called incomplete fracture.

The descript syndrome presents as a relatively common occurrence in dental practice, but often leaves the dental surgeon in an enigmatic situation, since it is not always possible to perform the diagnosis clearly and accurately. This is because, for the most part, the signs and symptoms are nonspecific, the cracks are not visible during the clinical analysis nor even identifiable in routine radiographic projections.(5)

The etiology and predisposing factors of this syndrome have multifactorial characteristics. Morphological, physical and iatrogenic aspects, such as deep grooves, pronounced fluctuation of intraoral temperature, poor design of cavity preparation, erroneous selection of restorative materials,(6) functional habits, chewing of hard objects, excessive occlusal forces, placement of intraradicular pins, use of rotating instruments, physical trauma, premature contact, teeth weakened by resorption (internal or external), and / or caused by some iatrogeny may predispose the posterior teeth to an incomplete fracture.(7)

Diagnosis in the past was based exclusively on the patient's reported symptoms. But today, in addition to the described symptoms, there are methods that help to realize the diagnosis of RDS. If a tooth is restored, removal of the restoration with subsequent use of stains for coloring the fracture line, use of a magnifying glass, a microscope, and even computed tomography may favor cracking.

The clinical signs and symptoms of RDS are varied according to the extent and depth of the fracture.(8) The patient usually reports painful symptoms with discomfort during the chewing of harder foods.(9) This is because the pressure promoted by occlusal forces on the crown of a cracked tooth causes small movements and slight removal of the cracked fragments,(10) resulting in hydraulic movement of the dentinal fluid, activation of the myelinated fibers and finally stimulation of odontoblasts creating a rapid and intense. In addition to the characteristic symptoms there may be sensitivity to temperature variation, especially to cold and sensitivity to chewing sweets and acidic foods.(8)

The prognosis is directly related to three factors: the extent and location of the fracture, the time of the intervention and the type of restoration.(5) This causes the symptoms to be dependent on the severity of the fracture, which may be small, resulting in a simple sensitivity(11) without the need for invasive treatment, or may be severe, resulting in endodontic treatment or even tooth loss.(12)

Treatment will depend on the location and extent of the fracture. The closer to the pulp, the worse the treatment and prognosis of the tooth, so early diagnosis is very important. There is no current evidence to show that the treatment option has the highest success rate, both from a restorative perspective and from a pulp health point of view.(12)

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The condition is found mainly in patients over the age of 40.(13) Men and women are equally affected.(14) The most affected teeth are the first maxillary molar, followed by the lower first molar, the second mandibular molar and the second mandibular molar.(13) While fractures tend to mesiodistal orientation in most teeth, mandibular molars may occur in the buccolingual orientation.(15)

The clinical case aims to show the importance of early diagnosis and treatment of a tooth that presents a vertical crack.

Case report

A female patient, without systemic involvement, sought endodontic treatment due to an acute pain in the tooth. Anamnesis and extra-oral and intra-oral clinical examination were performed. Clinically an amalgam restoration was observed in the occlusal without infiltration and without any visible fracture type. All sites were probed and there was no periodontal impairment. In the palpation and percussion tests, the patient reported painful symptoms. During the thermal test, he reported intense pain, which took a few seconds to pass and, radiographically, no periapical lesion was present (Figure 1).

Figure 1: Initial radiograph

Based on these tests, a diagnosis of terminal irreversible symptomatic pulpitis

can be reached. For the endodontic treatment, the chemical-mechanical preparation (PQM) associated with 1% sodium hypochlorite was performed (Asfer Indústria Química Ltda, São Caetano do Sul, SP, Brazil) as auxiliary chemical. Anesthesia and total removal of the amalgam restoration was done (Figure 2) where it was possible to perceive a darkened line from mesial to distal in the vertical direction. Apparently it appeared to be a fracture, but with endondontic nails (Dentsply-Maillefer-Ballaigues, Switzerland) it was realized that there was no separation of fragments. A fissure or incomplete fracture was suspected.

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Figure 2: After removing the amalgam restoration

Coronary opening was performed with a 1014 drill bit (K.G.Sorensen Ltda,

Barueri, SP, Brazil) and endo-Z drill ceiling removal (Dentsply-Maillefer, Ballaigues, Switzerland). Then absolute insulation was performed and at this stage the crack length was observed in the mesio-distal direction and it was concluded that it was an incomplete fracture (Figure 3).

Figure 3: Clinical image of the mesio-distal fracture line

After the coronary access, the channels were penetrated with K # 10 file

(Dentsply-Maillefer, Ballaigues, Switzerland) and pre-enlarged with the FileProglider (Dentsply-Maillefer, Ballaigues, Switzerland). Odontometry was initially performed with Romiapex apical locator (Romidan LTD, Kiryat-Ono, Israel) and confirmed with FIT digital sensor x-ray (Micro Image, Indaiatuba, SP, Brazil). The instrumentation was made as a reciprocating systemWaveOne Gold (Dentsply-Maillefer, Ballaigues, Switzerland) using the VDW Silver engine (VDW Germany, Munich). The mesiobuccal canal was modeled with instrument # 35/06 (medium), whereas the distobuccal and palatal channels, with instrument # 45/05 (large).

At the end of the instrumentation, the EDTA Trissodic 17% (Biodynamic Quim and Farm. Ltda - Ibiporã, PR, BR) was used for 3 min to remove the smear layer produced after instrumentation. The channels were dried with sterile paper tips (DentsplyInd Com LTDA, RJ, Petrópolis, Brazil) and the calcium hydroxide paste Calen (SS WhiteDuflex, Rio de Janeiro, Brazil) was placed.

After the conclusion of the first session, the patient was clarified about the treatment options and that the maintenance of the tooth would be a viable attempt, however, the prognosis would be reserved. After contact with the specialist in

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rehabilitation, we opted for endodontic treatment followed by prosthetic rehabilitation with total crown, aiming to stabilize the crack region.

After three days, a single taper of Tanari (Tanariman Industrial LTDA, Manacapuru, AM, Brazil) was performed, compatible with WaveOne Gold and AH Plus cement (Dentsply-Maillefer, Ballaigues, Switzerland) (Figure 4).

Figure 4: X-ray of the obturation

Immediately after the obturation of the root canal system, the sealing of the

mouthpieces with provisional shutter Villevie (Dentalville do Brazil LTDA, Joinville, SC, Brazil) was performed and provisional restoration with Maxxion R glass ionomer cement (FGM Produtos Odontológicos, Joinville, SC, Brazil). (Figure 5). The patient was referred for prosthetic rehabilitation.

Figure 5: Radiography with the provisional restoration of VSD

Discussion

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The American Association of Endodontics (EPA) in 1997 proposed a classification of four different categories of fractures (fractured cusp, split tooth, split tooth, and vertical root fracture) through clinical features and factors such as age, sex, signs and symptoms, cracking direction, restoration type and size, and diagnostic methods. However, because they are not completely clear and overlap one another, Abbott and Leow(16) proposed a simpler and clearer classification by dividing the fractures into three categories only: enamel cleft (small slits visible on the surface of the enamel without dentin involvement , asymptomatic, but need periodic monitoring, since they may evolve); (there may be involvement of other structures of the tooth as cement or restorative material, being able to reach the pulp and the periodontal ligament as the fracture progresses and there is no separation of the dental segments and complete fracture (there is a compromise of the dentine and, consequently, pulpal tissue and periodontal ligament, the diagnosis is relatively simple, because in this case the fragments separate). This classification, in turn, is subdivided into oblique, vertical and horizontal.(12)

Fissures in enamel are small surface cracks, without the involvement of dentin. They are asymptomatic but require periodic follow-up, as they may evolve and become a deeper fracture.(17) Incomplete fractures may compromise other structures of the tooth, such as cement or restorative material, and may reach the pulp and the periodontal ligament as the fracture progresses without separation of tooth segments.(4) In complete fractures there is involvement of dentin and, consequently, pulp tissue and periodontal ligament, in which case the fragments separate.(14) In the case reported, it had an incomplete vertical fracture in which it reached the dental pulp.

The most common cause of RDS is the accidental bite of an object or food of a hard consistency (a seed, for example), especially on a restored tooth, as an excessive load of force is directed to a small area of contact in the tooth,(14) favoring the formation of the cleft. In the case presented the patient had an occlusal restoration of amalgam and, according to her report, the tooth had begun to present symptomatology without memory of specific episode, like the chewing of more consistent food.

Studies show that in the posterior teeth 4.4 out of 100 teeth fracture in adults(12,14) with 15% of the fractures resulting in pulp involvement or exodontia. Thus, one out of 23 individuals fractures one posterior tooth per year.(14) However, it has been reported that 20% of patients who go to endodontists seeking diagnosis are often not diagnosed with an incomplete fracture. that SDR is a frequent occurrence, although it is not well reported due to difficulties in diagnosis. Thus, the condition is delayed to be identified and is only diagnosed when the symptoms resemble those of an endodontic problem, that is, until the pulp becomes inflamed and consequently necrotic, or when the crack reaches the external surface of the root and is similar to the periodontal symptoms characterized by the development of periodontal pockets and / or abscesses.(6) In the case of the patient, the symptoms arose and the problem was only diagnosed when the pulp had already been reached and was in an irreversible process.

In an investigation by Hiatt(2) still in 1973 it was possible to observe a high percentage (74%) of fractured teeth without restoration or with the presence of a class I restoration. More recently, Roh and Lee(18) analyzed 154 teeth that presented with fractures and a large part (89.6%) were healthy or with minimal restoration. Therefore, the possibility of a fracture in a tooth without restoration or with restoration

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of only one face should not be neglected, since it does not depend on the presence or the extension of the restoration, agreeing with the presented case.

The decision whether or not to treat closed teeth involves factors such as prognosis, cost, and treatment time.(19) Even a crack being identified, it is difficult to assess the prognosis of the involved tooth, because there is no precise way of knowing how deep this crack in the dental structure.(13) Belobrov et al.(20) have shown that it is worth trying conservatively in cases of neck fractures, especially in young patients. The treatment in question was decided after clarifying all the advantages and disadvantages for the patient. She was aware that this treatment would be an attempt to save the tooth, and that the prognosis was bleak. However, it would be the most feasible, as it would be a faster procedure in the event of an exodontia and subsequent implant surgery.

Conclusion

According to the presented case, it was possible to conclude that: - The early diagnosis of the fissure is essential so that there is no progression of the same to the pulp or root preventing the recovery of the tooth - Cracked teeth, when well diagnosed, can be treated and kept in the oral cavity. References 1. Fernandes LHF, Figueiredo TRM, Aguiar YPC, Cardoso AMR, Cavalcanti AL. Ocorrência de fratura dentária em escolares de 12 anos. RSC online. 2017;6(1), 28-38.Avaliablefrom: http://www.ufcg.edu.br/revistasaudeeciencia/index.php/RSC-UFCG/article/view/450/288 2. Hiatt WH. Incomplete crown-root fracture in pulpal-periodontal disease.JPeriodontol.1973;44(6), 369-79.Avaliable from: https://onlinelibrary.wiley.com/doi/pdf/10.1902/jop.1973.44.6.369 3. Cameron CE. Cracked-tooth syndrome.J Am Dent Assoc. 1964;68, 405-11.Avaliable from: https://jada.ada.org/article/S0002-8177(64)83010-5/pdf 4. Avelar WV, Medeiros AF, Ramos T de O, Vasconcelos MG, Vasconcelos RG. Síndrome do dente rachado: etiologia, diagnóstico, tratamento e consideraçõesclínicas. OdontologiaClínicoCientífica. 2017;16(1), 7-14.Avaliablefrom: http://cro-pe.org.br/site/adm_syscomm/publicacao/foto/128.pdf#page=9 5. Banerji S, Mehta SB, Millar BJ. Cracked tooth syn-drome. Part 1: a etiology and diagnosis. Br Dent J.2010;208(10), 459-63.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/20489766 6. Vieira MVB. Síndrome do dente rachado. RBO.2008; 65(2), 150-1.Avaliable from:http://revista.aborj.org.br/index.php/rbo/article/view/35/39 7. Berman LH, Kuttler S. Fracture Necrosis: Diagnosis, Prognosis Assessment, ande Treatment Recommendations. USA Journal of Endodontology.2010;36(3), 442-6.Avaliable from: https://www.jendodon.com/article/S0099-2399(09)01070-X/pdf 8. Monteiro Júnior RS, Andrada APSC, Schrickte N, Arcari GM. Síndrome do dente rachado. JBD. 2002; 1(3), 185-92.Avaliablefrom: https://www.dtscience.com/wp-content/uploads/2015/10/Sindrome-do-Dente-Rachado.pdf 9. Batalha-Silva S, Gondo R, Stolf SC, Baratieri LN. Cracked Tooth Syndrome in an Unrestored Maxillary Premolar: A Case Report.Oper Dent.2014;39(5), 460-8.Avaliable from: http://www.jopdentonline.org/doi/pdf/10.2341/13-257

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10. Naik SB, Raghu R,Gautham. Cracked tooth syndrome – a review and report of an interesting case. Archives of Oral Sciences & Research.2011; 1(2), 84-9. 11. Mamoun JS, Napoletano D. Cracked tooth diagnosis and treatment: An alternative paradigm. Eur J Dent. 2015; 9(2), 293–303.Avaliable from: http://www.eurjdent.com/temp/EurJDent92293-3399781_092637.pdf 12. Lubisich EB, Hilton TJ, Ferracane J. Cracked Teeth: A Review of the Literature. J EsthetRestor Dent. 2010;22(3), 158-67.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/20590967 13. Seo DG, Yi Y, Shin SJ, Park JW. Analysis of factors associated with cracked teeth. J Endod.2012;38(3), 288-92.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/22341061 14. Geurtsen W, Schwarze T, Gunay H. Diagnosis, therapy, and prevention of the cracked tooth syndrome. Quintessence Int. 2003;34(6), 409-17.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/12859085 15. Turp JC, Gobetti JP. The cracked tooth syndrome: An elusive diagnosis.J Am Dent Assoc. 1996;127(10), 1502-7.Avaliable from: https://jada.ada.org/article/S0002-8177(15)61211-9/pdf 16. Abbott P, Leow N. Predictable management of cracked teeth with reversible pulpitis. Aust Dent J. 2009; 54(4), 306-15.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/20415928 17. Boushell LW. Cracked tooth Journal of Esthetic and Restorative Dentistry.2009;21(1), 68-9. 18. Roh BD, Lee Y. Analysis of 154 cases of teeth with cracks. Dent Traumatol. 2006;22(3), 118-23.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/16643285 19. Ruiz NT, Duque TM, Marion JJ de C. Diagnóstico e tratamento de trincanaregião de furca de molar superior: relato de caso. BJSCR.2014;8(3), 33-9.Avaliable from: https://www.mastereditora.com.br/periodico/20141101_221803.pdf 20. Belobrov I, Weis MV, Parashos P. Conservative treatment of a cervical horizontal root fracture and a complicated crown fracture: a case report. Aust Dent J. 2008; 53(3), 260-4.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/18782371

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EVALUATION OF ORAL MANIFESTATIONS IN CHRONIC RENAL PATIENTS

EVALUACIÓN DE MANIFESTACIONES BUCALES EN PACIENTES RENALES CRÓNICOS

AVALIAÇÃO DE MANIFESTAÇÕES BUCAIS EM PACIENTES RENAIS CRÔNICOS Francisco Bruno Nunes Nascimento Silva1, João Marcelo vieira da Silva2, Ginivaldo Victor Ribeiro do nascimento3, Claudia Fernanda Caland Brígido4 1 – Centro Universitário UNINOVAFAPI. Graduated in Dentistry. Email: 2 – Centro Universitário UNINOVAFAPI. Graduated in Dentistry. Email: 3 – Universidade Estadual do Piauí. PhD in physiopathology in medical practice. Email: 4 – Centro Universitário UNINOVAFAPI. PhD in Cellular and Molecular Biology Applied to Health. E-mail: cbrigido@uninovafapi.edu.br Claudia Fernanda CalandBrígido (Corresponding author) Centro Universitário UNINOVAFAPI. PhD in Cellular and Molecular Biology Applied to Health E-mail: cbrigido@uninovafapi.edu.br

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Abstract Objective: To identify the oral manifestations in patients with CKF on hemodialysis. Material and Methods: A cross-sectional study with 183 patients undergoing hemodialysis treatment at the Teresina-pi renal care center. Cross-sectional study, with 183 patients, after informed consent, using a semi-structured questionnaire. Results: Regarding oral hygiene care, the majority reported having a good frequency of daily brushing, but they do not floss adequately and do not make periodic visits to the dental surgeon. The numbers point to halitosis, lingual sores and dental calculus as the most common manifestations in chronic kidney patients being mostly men with more advanced age. Conclusions: The oral manifestations resulting from chronic kidney disease were present in a very significant percentage of the patients surveyed, even in those who reported greater care with oral hygiene. Keywords: Renal Insufficiency, Chronic; Renal Dialysis; Oral Manifestations. Resumen: Objetivo: Identificar las manifestaciones orales en pacientes con IRC en hemodiálisis. Material y Métodos: Estudio transversal, con evaluación de 183 pacientes en tratamiento hemodialítico en el centro de terapia renal de Teresina- pi. Estudio transversal, con evaluación de 183 pacientes, después de consentimiento esclarecido, utilizando un cuestionario semiestructurado. Resultados: En relación a los cuidados con la higienización oral, la mayoría afirmó tener una buena frecuencia de cepillados diarios, pero no utilizan hilo dental de forma adecuada y ni hacen visitas periódicas al cirujano. Los números apuntan halitosis, saburra lingual y cálculo dental como las manifestaciones más comunes en los pacientes renales crónicos siendo en su mayoría hombres con rango de edad más avanzada. Conclusiones: Las manifestaciones orales derivadas de la enfermedad renal crónica estuvieron presentes en un porcentaje bastante significativo de los pacientes investigados, incluso en aquellos que relataron mayores cuidados con la higienización oral. Palabras clave: Insuficiencia Renal Crónica; Diálisis Renal; Manifestaciones Bucales. Resumo Objetivo: Identificar as manifestações orais em pacientes com IRC em hemodiálise. Material e Métodos: Estudo transversal, com avaliação de 183 pacientes em tratamento hemodialítico no centro de terapia renal de Teresina- pi. Estudo transversal, com avaliação de 183 pacientes, após consentimento esclarecido, utilizando-se um questionário semiestruturado. Resultados: Em relação aos cuidados com a higienização oral, a maioria afirmou ter uma boa frequência de escovações diárias, porém não utilizam fio dental de forma adequada e nem fazem visitas periódicas ao cirurgiãodentista. Os números apontam halitose, saburra lingual e cálculo dentário como as manifestações mais comuns nos pacientes renais crônicos sendo em sua maioria homens com faixa etária mais avançada.

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Conclusões: As manifestações orais decorrentes da doença renal crônica estiveram presentes numa porcentagem bastante significativa dos pacientes pesquisados, mesmo naqueles que relataram maiores cuidados com a higienização oral. Descritores:Insuficiência Renal Crônica; Diálise Renal; Manifestações Bucais. Introduction

Chronic Kidney Failure (CKF) is defined by a syndrome characterized by the slow, progressive and irreversible destruction of the nephrons. Glomerular filtration when decreased causes uremia, which is characterized by accumulation of toxic substrates in the blood. With their regenerative inability, the remaining nephrons begin a process of hypertrophy, so that even reduced, they can fulfill the role of the kidneys completely. From 75% of nephrological loss renal capacity goes into failure and the clinical manifestations of chronic renal failure begin.(1)

CKF is reported for symptoms and laboratory evaluation. Its clinical manifestation will depend on the degree of dysfunction, generally observing hypertension and nocturia. A total of 90% of the patients present oral manifestations, being more common the paleness of the oral mucosa, derived from the anemic state in most cases. A breath with ammonia odor may be present due to urea elevation, taste alterations, xerostomia, gingivitis, parotitis, angular cheilitis, among others. Accumulation of calculus, dental mobility and malocclusion are also common symptoms.(1-2)

Although the criteria for diagnosis of chronic kidney disease are very clear, the proportion of patients with advanced CRI going to the single nephrologist and immediately prior to initiation of dialysis treatment is unacceptable. Early diagnosis and referral to the nephrologist are essential steps in the management of these patients, since they enable pre-dialysis education and the implementation of a preventive protocol, in order to avoid complications of the disease, and delay the progression of the disease, disease.(3-4)

The research aims to identify the oral manifestations in patients with CKF on hemodialysis.

Materials and Methods

Quantitative and descriptive research was carried out at the Teresina-PI renal

therapy center.(5-6) Eighty-one patients were eligible in the study where only 111 met the inclusion criteria. We included: patients from the Renal Therapy Center (CTR), patients with chronic renal failure with frequent hemodialysis, classified as ASA III (American Society of Anesthesiologists) and who were in a systemic condition that allowed clinical examination. The following were excluded: patients diagnosed with CKF less than one month; women in gestation or lactation; with trauma or maxillofacial facial fractures; severe systemic diseases not related to CKF; use of alcohol, drugs or tobacco or under 18 years.

Participants answered a questionnaire that included questions about personal data, socioeconomic conditions, time and evolution of CKF, oral hygiene habits and frequency of hygiene. After application of the questionnaires, oral clinical examinations of the patients under artificial light were carried out by a researcher, with the aid of tongue depressors, duly protected with personal protective equipment.

Statistical analysis was performed by the IBM SPSS program, Fisher's exact test was used to verify statistical associations of 95% (p = 0.5).

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This research was approved by the Ethics Committee of the UNINOVAFAPI University Center, CAAE: 58224816.40000.5210. Information was provided regarding the objectives of the study and all the participants signed the Informed Consent Term. Results

The largest proportion of the patients in the study was male, with a total of

66.6%, while the female sex was 33.3%. The most frequent oral manifestation was the lingual plaque present in 72.97% of the patients, followed by dental calculus with 72.07%, halitosis with 70.27% gingival recession with 66.67%, xerostomia with 52.25 %, ulcerative lesions 23.42%, gingival hyperplasia 21.62% and dental mobility with 16.22%. Only one patient presented no oral changes as shown in Table 1.

Table 1 - Mouth alterations by sex, Teresina, PI, Brazil, 2016 (n = 111)

Sex Male Female Total

n % n % n %

Halitosis 51 68,9 27 72,9 78 70,27 Lingual sores

56 75,6 25 67,5 81 72,9

Ulcerative Injuries

22 29,7 4 10,8 26 23,4

Gingival hyperplasia

19 25,6 5 13,5 24 21,6

Xerostomia 34 45,9 24 64,8 58 52,2

Gingival Recession

54 72,9 20 54,0 74 66,6

Dental mobility

14 18,9 4 10,8 18 16,2

Dental calculus

59 79,7 21 56,7 80 72,0

No oral changes

- - 1 2,7 1 0,9

Total 100,00 100,00 111 100,00 Source: Direct Search. It amounts to more than 100%. A patient may have more than one change.

Regarding the age group, oral alterations are found mostly in patients with

more advanced ages, except for the dental calculus, which was present mostly in patients aged between 18 and 44 years and 45 and 59 years, representing a percentage of 90.32% and 84.85%, respectively, according to Table 2.

Table 2 - Oral changes by age group, Teresina, PI, Brazil, 2016 (n = 111)

Age group

18 a 44 45 a 60 60 or more Total

n % n % n % n %

Halitosis 18 58,0 21 63,6 39 82,9 78 70,2

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Lingual sores

17 54,8 21 63,6 43 91,4 81 72,9

Ulcerative Injuries

6 19,3 8 24,2 12 25,5 26 23,4

Gingival hyperplasia

10 32,2 4 12,1 10 21,2 24 21,6

Xerostomia 17 54,8 13 39,3 28 59,5 58 52,2

Gingival Recession

24 77,4 28 84,8 22 46,8 74 66,6

Dental mobility

4 12,9 7 21,2 7 14,8 18 16,2

Dental calculus

28 90,3 28 84,8 24 51,0 80 72,0

No oral changes

- - 1 3,0 - 1 0,9

Total 31 100,00 33 100,00 47 100,00 111 100,00

Source: Direct Search. It amounts to more than 100%. A patient may have more than one change.

During the questionnaire, a high number of reports of other systemic diseases

that CKF patients suffered were perceptible. Changes such as high blood pressure, diabetes, heart disease, lumbar and other problems were recorded. Arterial hypertension assumed a prominent role, representing a percentage of 59.46%, followed by diabetes and heart disease, both with 27.03%, with another 16.22% and with low back problems with 7.21%. Patients without CKF-associated alterations accounted for a total of 26.13%. Another important point was the higher prevalence of these diseases in male patients, except for the back problems that affected women in 13.51%, according to Table 3.

Table 3 - Systemic changes by sex Teresina, PI, Brazil, 2016 (n = 111)

Sex

Male Female Total

n % N % n %

Hypertension 19 52,7 27 72,9 66 59,4

Diabetes Mellitus

15 20,2 15 40,5 30 27,0

Cardiac diseases

17 22,9 13 35,1 30 27,0

Back problems

3 4,0 5 13,5 8 7,2

Others

10 13,5 8 21,6 18 16,2

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No systemic changes

21 28,3 8 21,6 29 26,1

Total 74 100,00 37 100,00 111 100,00 Source: Direct Search. It amounts to more than 100%. A patient may have more than one change.

Regarding the relation of the systemic alterations with the age group of the

patients studied, the problems continue to occur mostly individuals with more advanced ages representing as a highlight the arterial hypertension that affects 70.21% of the cases approached. Patients without associated alterations are found mostly in the age group of 18 to 44 years as shown in table 4.

Table 4 - Systemic changes by age group. Teresina, PI, Brazil, 2016 (n = 111)

Age group

18 a 44 45 a 59 60 or more Total

n % n % N % n %

Hypertension 15 48,3 18 54,5 33 70,2 66 59,4

Diabetes Mellitus

2 6,4 11 33,3 17 36,1 30 27,0

Cardiac diseases

3 9,6 9 27,2 18 38,3 30 27,0

Back problems

1 3,2 1 3,0 6 12,7 8 7,2

Others

3 9,6 6 18,1 9 19,5 18 16,2

No systemic changes

12 38,7 8 24,2 9 19,5 29 26,1

Total 31 100,00 33 100,00 47 100,00 111 100,00

Source: Direct Search. It amounts to more than 100%. A patient may have more than one change.

Discussion

When CKF is discovered early, it can be treated through conservative therapeutic measures involving changes in eating habits, use of medications, and control of risk factors. While these interventions do not lead to a satisfactory outcome, it is considered necessary to initiate a dialysis treatment in order to maintain the quality of life of the patient and treat the first signs and symptoms of uremia that will begin to arise.(4)

Some interventions are said to be crucial for decreasing the progression of CKF. Blood pressure (BP) control in addition to decreasing complications during treatment represents a considerable decrease in the risk of developing associated cardiovascular diseases.(7)

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CKF is clinically reported by symptoms and laboratory evaluation. Its clinical manifestation will depend on the degree of dysfunction, generally observing hypertension and nocturia. The dental treatment performed in conditions to minimize the risks of infection to the patient constitutes a practice of care and assistance necessary to maintain the health of patients with chronic renal failure.(8)

Among the oral manifestations of chronic kidney disease, halitosis, xerostomia, gingival hyperplasia, dental mobility, dental calculus, gingival recession, lingual sores, ulcerative lesions, among others, are prominent. Most patients with CKF present oral manifestations resulting from the disease. The anemic state of the patient often causes a pallor in the mucosa being the most noticeable feature among them. Due to the elevation in urea levels in the body, the appearance of a breath with ammonia odor, besides alterations in the palate, gingivitis, parotiditis, angular cheilitis, among others.(9)

Dental alterations are frequently detected in patients with CKF, the most common being enamel hypoplasia, root lesions, narrowing of the pulp chamber and dental erosion. Periodontal problems also appear due to accelerated-level accumulation of calculus that may be related to an altered serum calcium phosphate product. The gums tend to be inflamed and prone to bleeding. In more advanced cases of CKF, candida infections are prominent in the oral cavity involving about 37% of patients.(10)

Regarding the dental treatment of these patients, Guevara et al.(11) cite that specific considerations should be made, especially regarding the risk of excessive bleeding, infection and medications to be used. When the patient is under control, a traditional treatment is performed, however, in patients without adequate control, consultation with the physician should be made. You should request a complete blood count, coagulation tests, and check blood pressure every time. 9 One of the crucial factors for the increase in mortality in patients with early stages of CKF is directly related to blood pressure levels resulting in deaths due to cardiovascular problems. Lower pressure carriers are not excluded from this list and also have an increased cardiovascular risk when they are associated with CKF.(8)

Regarding diabetes, a problem routinely found in patients with CKF, there is no consensus in the literature regarding glycemic control as a direct protective action of nephropathy patients, however, such care is recommended as a preventive action to delay the progression of microalbuminuria and of micro and macrovascular complications of diabetes. Smoking, obesity and excessive protein intake are also complicating in the treatment of CKF and should be controlled as a strategy to delay the progression of the disease.(11)

With CKF, patients become discouraged, desperate people, and for the most part for these reasons or for lack of guidance they end up abandoning nephrological treatment as a form of slow suicide or fail to give importance to the constant care they should have, both with(12) Souza et al.(9) emphasized that hemodialysis patients need dental care and oral hygiene guidelines, and should be made aware of the importance of health the maintenance of their systemic condition.

Conclusion

In this study it was verified that some oral manifestations are present in a

significant way in patients with chronic renal failure, from problems caused by poor oral hygiene to problems triggered using drugs in the treatment of systemic disease.

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It was also observed that worsening periodontal problems are directly related to a longer time of hemodialysis treatment.

There were also high numbers of cases of systemic diseases associated with the kidney problem, highlighting arterial hypertension and diabetes as great villains in the prognosis of these patients. Thus, it is clear the need for periodic dental care and awareness of the importance of maintaining oral health in patients with CKF. References 1.Medeiros NH, Neves RRA, Amorim JNC, Mendonça SMS. A insuficiência renal crônica e suas interferências no atendimento odontológico – revisão de literatura. Rev Odontol Univ Cid São Paulo. 2014; 26(3), 232-42. Avaliablefrom: http://files.bvs.br/upload/S/1983-5183/2015/v26n3/a4997.pdf 2. Souza AL, Mello ALSF, Carcereri DL, Caetano JC, Godoi H. Atenção à saúde bucal dos portadores de insuficiência renal crônica: interfaces com a rede de atenção à saúde. Saúde em debate. 2011; 35(90), 477-84. Avaliablefrom: http://www.redalyc.org/pdf/4063/406341766016.pdf 3. Bastos MG, Kirsztajn, G.M. Doença renal crônica: importância do diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada para melhora do desfecho em pacientes ainda não submetidos à diálise. Jornal Brasileiro de Nefrologia. 2011; 33(1), 93-108. Avaliablefrom: http://www.scielo.br/pdf/jbn/v33n1/v33n1a13.pdf 4. Thomé FS, Gonçalves LF, Manfro RC, Barros, E. Nefrologia: rotinas, diagnóstico e tratamento. Artmed. 2007; 24:381-404. 5. Moura LKB, Mesquita RF, Mobin M, Matos FTC, Monte TL, Lago EC, et al. Uses ofBibliometricTechniques in Public Health Research. IranianJournalofPublic Health. 2017; 46(10), 1435-6. Avaliablefrom: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750357/ 6. SousaLRM, Mesquita RF, Matos FRN, Moura LKB, Moura MEB. Dimensões da satisfação dos usuários da Estratégia Saúde da Família. Revista Portuguesa de Investigação Comportamental e Social. 2017,3(2), 2-9.Avaliablefrom: https://dialnet.unirioja.es/servlet/articulo?codigo=6126343 7.Bastos MG, Carmo WB, Abrita RR, Almeida EC, Mafra D, Costa DMN, et al. Doença renal crônica: problemas e soluções. J Bras Nefrol. 2004; 26(4), 203-15. Avaliablefrom: http://www.bjn.org.br/details/313/en-US/chronic-kidney-disease--problems-ad-solutions 8. Bortolotto LA. Hipertensão arterial e insuficiência renal crônica. Rev Bras Hipertens. 2008; 15(3), 152-5. Avaliablefrom: http://departamentos.cardiol.br/dha/revista/15-3/09-hipertensao.pdf 9. Souza FF, Cintra FA, Gallani MCBJ. Qualidade de vida e severidade da doença em idosos renais crônicos. Rev Bras Enferm. 2005; 58(5), 540-4. Avaliablefrom: http://www.scielo.br/pdf/reben/v58n5/a08v58n5.pdf 10. Silva LCF. Manifestações orais em pacientes portadores de insuficiência renal crônica em programa de hemodiálise e em transplantados renais sob terapia imunossupressora. Dissertação (mestrado em patologia oral). 2000; 1, 18-33. 11. Guevara HG, Mónaco GL, Rivero CS, Vasconcellos V, Sousa DP, Raitz R. Manejo odontológico em pacientes com doença crônica. Revista brasileira de ciências da saúde. 2014; 12(40), 74-81.Avaliablefrom: https://www.researchgate.net/publication/273660530_MANEJO_ODONTOLOGICO_EM_PACIENTES_COM_DOENCA_RENAL_CRONICA

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12. Resende MC, Santos FA, Souza MM, Marques TP. Atendimento psicológico a pacientes com insuficiência renal crônica: em busca de ajustamento psicológico. PsicClin. 2007; 19(2), 87-99.Avaliablefrom: http://www.scielo.br/pdf/pc/v19n2/a07v19n2.pdf

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PREVALENCE OF DIASTEMA BETWEEN UPPER CENTRAL INCISORS UPPER

IN PATIENTS WITH AGENESIS OF THE LATERAL MAXILLARY INCISOR

PREVALENCIA DE DIASTEMAS ENTRE INCISIVOS CENTRALES SUPERIORES EN PACIENTES CON AGENESIA DE INCISIVO LATERAL SUPERIOR

PREVALÊNCIA DE DIASTEMAS ENTRE INCISIVOS CENTRAIS SUPERIORES EM

PACIENTES COM AGENESIA DE INCISIVO LATERAL SUPERIOR

Elida Francinne de Moura Barros1, Wilana da Silva Moura2, José Fernando Castanha Henriques3, Jairo de Abreu Ferreira4, Gregorio Antonio Soares Martins5

1 – E-mail: elidafrancinne@hotmail.com 2 – Faculdade de Odontologia de Bauru - University of São Paulo. PhD student in Applied Odontological Sciences. Email: wilanamoura@gmail.com 3 – Faculdade de Odontologia de Bauru - University of São Paulo. PhD in Dentistry. Email: jfchenri@fob.usp.br 4 - São Leopoldo Mandic Dental Research Center - Campinas. Doctor of Orthodontics. Email: jairoorto@hotmail.com 5 – São Leopoldo Mandic Rsearch Center – Campinas .PhD in Dentistry. E-mail: gregoriomartins@gefocus.com.br Jairo de Abreu Ferreira (Corresponding author) Faculdade de Odontologia de Bauru - University of São Paulo E-mail: jairoorto@hotmail.com

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Abstract Objective: To evaluate the presence of diastema between upper central incisors in patients with lateral incisor agenesis and to analyze if there is a relationship between the amount of diastema and the positioning of the incisors. Materials and methods: We evaluated 542 patient documentation and 5 were selected according to the inclusion criteria. Pearson's descriptive statistics and correlation were used. Results: The presence of diastema between the upper central incisors was observed in 100% of the sample, with the majority of participants being male, brachyfacial pattern, with superior incisor incisors and positioned in the anteroposterior direction. Positive correlation was observed between the amount of diastema and the AP position of the upper incisors. Conclusion: The present study observed the presence of diastema between upper central incisors in all cases with lateral incisor agenesis evaluated and a positive correlation between the amount of diastema and the AP position of the upper incisors. Keywords:Anodontia; Diastema; Prevalence. Resumen Objetivo: Evaluar la presencia de diastema entre incisivos centrales superiores en pacientes con agenesia de incisivo lateral y analizar si existe relación entre la cantidad de diastema y el posicionamiento de los incisivos. Materiales e Métodos: Se evaluaron 542 documentaciones de pacientes y 5 fueron seleccionados según los criterios de inclusión. Se utilizó estadística descriptiva y correlación de Pearson. Resultados: En el 100% de la muestra se observó la presencia de diastema entre los incisivos centrales superiores, siendo que la mayoría de los participantes era del sexo masculino, patrón braquifacial, con incisivos superiores vestibularizados y colocados en el sentido antero-posterior. Se observó correlación positiva entre la cantidad de diastema y el posicionamiento AP de los incisivos superiores. Conclusión: El presente estudio observó la presencia de diastema entre incisivos centrales superiores en todos los casos con agenesia de incisivo lateral evaluados y una correlación positiva entre la cantidad de diastema y el posicionamiento AP de los incisivos superiores. Palabras-Clave:Anodoncia; Diastema; Prevalencia. Resumo Objetivo: Avaliar a presença de diastema entre incisivos centrais superiores em pacientes com agenesia de incisivo lateral e analisar se existe relação entre a quantidade de diastema e o posicionamento dos incisivos. Materiais eMétodos: Foram avaliadas 542 documentações de pacientes e 5 foram selecionados segundo os critérios de inclusão. Foi utilizada estatística descritiva e correlação de Pearson. Resultados: Em 100% da amostra foi observada a presença de diastema entre os incisivos centrais superiores, sendo que a maioria dos participantes era do sexo masculino, padrão braquifacial, com incisivos superiores vestibularizados e posicionados no sentido ântero-posterior. Correlação positiva foi observada entre a quantidade de diastema e o posicionamento AP dos incisivos superiores.

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Conclusão: O presente estudo observou a presença de diastema entre incisivos centrais superiores em todos os casos com agenesia de incisivo lateral avaliados e uma correlação positiva entre a quantidade de diastema e o posicionamento AP dos incisivos superiores. Descritores: Anadontia; Diastema; Prevalência. Introduction

The agenesis of upper lateral incisors has a great aesthetic and functional

impact for the anomaly patient, as well as for health professionals, making the treatment plan a great challenge.(1) A study by Pinho et al.(2) in the Portuguese population through the evaluation of 16,771 panoramic radiographs, found that 1.3% of the population had lateral incisor agenesis and a higher prevalence in females (59.8%).

The diastema between upper central incisors sends numerous doubts about the therapeutics to be used, becoming a focus of interest for several dentistry specialties. This malocclusion has a prevalence between 1.6% and 25.4% of the adult population, and is always higher in younger groups. Several factors may be related to the presence of diastema between upper central incisors, such as positive bone-tooth discrepancy, upper lateral incisor agenesis, microdontia of upper lateral incisors, heredity, and deleterious habits.(3)

A study by Al-Bitaret al.(4) sought to assess which dentofacial characteristics are considered causes of bullying among children and adolescents. The authors noted that the major cause of bullying reported was the presence of spaces between the upper teeth. Due to the unsightly condition to which it is associated, the presence of spaces in the upper arch, especially in the midline region, is responsible for the search for orthodontic treatment by many patients who seek treatment in order to improve the aesthetics of the smile.

One of the factors related to the presence of diastemas between upper central incisors is the agenesis of lateral incisors. Therefore, the present study aims to analyze the prevalence of diastema between upper central incisors in patients who have upper lateral incisor agenesis and to analyze the relationship between the amount of diastema and the positioning of the incisors.

Material and methods

The present study is a pilot study whose sample was selected through the

registration of patients from the Faculty of Uningá, Teresina - PI, using the clinical management program Dental Office® (RHSoftwere) Desktop version. To select the sample, the orthodontic models and cephalometric data of the patients were evaluated and the following inclusion criteria were applied: patients with lateral incisor agenesis; orthodontic models without fractures and zoned; patients without previous orthodontic treatment. After the analysis of 542 documents, 05 participants were selected. The research was approved by the ethics committee and the participants who agreed to participate in the study were informed about the study and were asked to sign the informed consent form.

The quantity of diastema between upper central incisors was measured through a digital caliper calibrated by IMETRO of the brand Mytutoio ®. The tilting and anteroposterior (AP) position of the upper incisors were evaluated according to the following cephalometric measures: 1.NA (inclination angle of maxillary central

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incisor in relation to maxillary projection - NA line, norm = 22º) and 1-NA millimeters of the distance from the cornea of the maxillary central incisor in relation to maxillary projection - line NA, norm = 4 mm), respectively. The facial vertical pattern of the patient was evaluated according to the FMA angle (angle formed between the Frankfurt plane and the mandibular plane), and the patient was considered mesofacial when the measurement of this angle was 25 ± 4º, brachyfacial when the measurement was less than 21º and dolichofacial when higher than 29º.

Systematic and casual errors were not calculated because it was a pilot study. After data collection and tabulation, statistical analysis was applied through the EXCEL 2010 program for data analysis. Descriptive analysis and Pearson correlation were used. Results

The presence of diastema was observed in all patients who had lateral incisor

agenesis selected in the sample. The majority of these patients were male, as shown in Graph 1.

Graph 1. Patients with upper lateral incisor agenesis in relation to sexual dimorphism. Source: Direct Search.

60% of the patients were brachyfacial, 40% mesofacial and no patient was

dolichofacial, according to Graph 2.

Graph 2. Patients with superior lateral incisor agenesis in relation to facial pattern. Source: Direct search

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The average inclination of the upper incisors evaluated in the sample was 29.27º, SD = 5.28, the mean AP position was 12.87 mm, SD = 11.56 and the mean diastema quantity was 2.26 mm, SD = 1.10, according to Table 1. Table 1 - Amount of diastema, inclination (1.NA) and protrusion (1-NA) of maxillary incisors in patients with lateral incisor agenesis.

Média DP Min Max

Diastema (mm) 2,26 1,10 1,46 4,15

1.Na (graus) 29,27 5,28 24,23 37,39

1-Na (mm) 12,87 11,56 6,41 31,16

Source: Direct search When the inclination and anteroposterior positioning of the upper incisors were

evaluated in detail, it was observed that most of the incisors were vestibularized and well positioned, respectively, according to Figure 3.

Graph 3: Inclination (1.NA) and AP position (1-NA) of maxillary incisors in patients with lateral incisor agenesis Source: Direct search

In this study, no correlation was observed between the inclination of the upper incisors evaluated by 1.Na and the amount of diastema (R = 0.19, Graph 4).

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Graph 4: Correlation between 1.Na and amount of diastema in patients with lateral incisor agenesis. Source: Direct Search

However, when the relationship between the AP position of the upper incisors and the amount of diastema was evaluated, a strong correlation was found (R = 0.74, Graph 5).

Graph 5: Correlation between 1-Na and amount of diastema in patients with lateral incisor agenesis. Source: Direct Search.

Discussion

The present study aimed to evaluate the prevalence of diastema in patients who had lateral incisor agenesis, therefore, it was necessary to identify the cases with agenesis. This explains in part the reduced sample, since according to Pinho et al.(2) this agenesis occurs in only 1.3% of the population. This study is also a pilot study, so the sample calculation was not performed.

The etiology of malocclusion encompasses several factors, including genetic factors, and the greater the contribution of this factor to the origin of a dentofacial irregularity, the more difficult it becomes prevention, and the worse the prognosis of orthodontic / orthopedic treatment.(5-6) Nowadays, the genetic factor has also been considered as the etiological factor of some dental anomalies.(7-8) Thus, because of the same etiological factor, the association between a malocclusion and a dental anomaly can be expected.

In this study, the presence of diastema was observed in 100% of the cases that had lateral incisor agenesis. Woodworthet al.(9) also reported dentofacial and craniofacial changes in patients with bilateral lateral incisor agenesis. The high prevalence of diastema in cases with lateral incisor agenesis was expected, since, according to Proffit(10) and Canuto et al.(11), lateral incisor agenesis may lead to the appearance of diastema between maxillary central incisors. Braga,(12) states that one of the consequences of dental agenesis is malocclusion due to the inadequate positioning of the teeth adjacent to agenesis, deficiency of alveolar process growth associated with tooth absence and presence of spaces in the dental arch, which can lead to inclination or supra-eruption of adjacent teeth or antagonists.

In this study, the majority of participants who had lateral incisor and diastema agenesis were male, contrary to the literature,(13) which shows a higher prevalence of female agenesis. This result may be a consequence of the small sample.

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It was observed that 60% of the patients selected for the study were brachyfacial and all had diastemas between the upper incisors. Currently the canine impaction is associated with the brachyfacial pattern and due to the association between the several dental anomalies in the same patient that denotes the possibility of a genetic defect leading to the appearance of several anomalies, such as lateral incisor agenesis, so the result obtained this study was expected.(7,14-15)

However, the study carried out in 2010 by Celikogluet al.(16), who sought to investigate the prevalence and characteristics of dental agenesis, did not observe a significant difference in the patients with hypodontia and the vertical relationship of the jaws. Regarding the presence of diastema, the Canuto et al.(11) study agrees with the results of this research, since it observed a statistically significant difference between the presence of diastemas and the mesofacial and brachyfacial patterns.

An association between the inclination of the incisors and the facial pattern was studied by Ambrosio.(17) The authors observed that the values found for the 1.NA of the three different groups (mesofacial, brachyfacial and dolichofacial) are in the normality pattern and are not possible to correlate the inclinations with the facial pattern.(17)

Wisthet al.(18) observed that patients with hypodontia in both sexes showed a greater inclination of the upper incisors. The values obtained by this study are in agreement, since in the majority of the sample the central incisors were vestibularized. In the sample obtained, it was observed that in the majority of cases, the upper central incisors were well positioned in the anteroposterior direction. No patient evaluated in this study had the mandibular or mandibular upper central incisors, which was expected, since the literature(19-21) agrees to include as one of the main complications due to agenesis space disorders the inclination to lingual of neighboring teeth and formation of diastema as a form of "adaptation to the present space".

When the correlation between amount of diastema and positioning of upper incisors in patients with lateral incisor agenesis was evaluated, a very weak correlation was observed between the inclination of the upper incisors and the amount of diastema and a very strong correlation between the antero- and the amount of diastema. However, it was believed that the greater the protrusion and vestibularization of the incisors, the greater the amount of diastema. Thus, due to the variation of the data analyzed in this study and the absence of similar studies, further studies are suggested.

Conclusion

The present study observed the presence of diastema between upper central

incisors in all cases with lateral incisor agenesis evaluated and a positive correlation between the amount of diastema and the protrusion of the upper incisors.

References 1. Salgado H, Mesquita P, Afonso A. Agenesia de incisivo lateral superior – a propósito de um caso clínico. Revportestomatolmeddentcirmaxilofac.2012; 53(3), 165 –9.Avaliablefrom: http://elsevier.pt/pt/revistas/revista-portuguesa-estomatologia-medicina-dentaria-e-cirurgia-maxilofacial-330/pdf/S1646289012000489/S300/

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2. Pinho T, Tavares P, Maciel P, Pollmann C. Developmental absence of maxillary lateral incisors in the Portuguese population. Eur. J. Orthod.2005; 27(5), 443-9.Avaliable from: https://academic.oup.com/ejo/article-lookup/doi/10.1093/ejo/cji060 3. Almeida RR, Garib DG, Almeida-Pedrim RR, Almeida MR, Pinzan A, Junqueira MH Z. Diastema interincisivos centrais superiores: quando e como intervir?.R Dental Press OrtodonOrtop Facial. 2004; 9(2), 137-56.Avaliablefrom: http://www.scielo.br/pdf/dpress/v9n3/v9n3a14.pdf 4. Al-BitarZB, Al-Omari IK, Sombol HN, Al-Ahmad HT, CunninghanSJ.Bullying among Jordanian schollchildren, its effect on scholl performance, and the contribution of general physical and dentofacialfeatures.Am J OrthodDentofacialOrthop.2013; 144(6), 872-8.Avaliable from: https://www.sciencedirect.com/science/article/pii/S0889540613008305?via%3Dihub 5. Garib DG, Alencar BM, Ferreira FV, Ozawa TO. Anomalias dentárias associadas: o ortodontista decodificando a genética que rege os distúrbios de desenvolvimento dentário. Dental Press J Orthod. 2010;15(2), 138-57. Avaliable from: http://www.scielo.br/pdf/dpjo/v15n2/17.pdf 6. Mossey P. The heritability of malocclusion: part 2. The influence of genetics in malocclusion. Br J Orthod. 1999; 26(3), 195-203. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/10532158 7. Garib DG, Peck S, Gomes SC. Increased occurrence of dental anomalies associated with second-premolar agenesis. The Angle orthodontist 2009;79(3), 436-41. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/19413376 8. Kurol J. Infraocclusion of primary molars: an epidemiologic and familial study. Community dent and oral epidemiol. 1981;9(2), 94-102. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/6946890 9. Woodworth DA, Sinclair PM, Alexander RG. Bilateral congenital absence of maxillary lateral incisor: a craniofacial and dental cast analysis. Am. J.Orthod.1985;87(4), 280-93.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/3857005 10. Proffit W, Fields H. Ortodontia Contemporânea. 2 ed. Rio de Janeiro: Guanabara Koogan.1995;596. 11. Canuto SB, Assis MS, Gouveia PMP, Nerm K. Análise comparativa entre presença de diastemas e tipos faciais. RevCEFAC. 2006; 8(2), 162:70.Avaliablefrom: http://www.redalyc.org/pdf/1693/169320515006.pdf 12. Braga T S. Uma Busca pelas causas genéticas de agenesias dentárias não sindrômicas. Trabalho de Conclusão de Curso. Universidade Federal do Rio Grande do Sul. 2009, 184p.

13. Polder BJ, Van’t Hof MA, Van der Linden FP, Kuijpers‐Jagtman AM. A

meta‐analysis of the prevalence of dental agenesis of permanent teeth. Community dent oral epidemiol. 2004; 32. (3), 217-26. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/15151692 14. Garn SM, Lewis AB. The gradient and the pattern of crown-size reduction in simple hypodontia. Angle Orthod. 1970;40(1), 51-8. Avaliable from: http://www.angle.org/doi/pdf/10.1043/0003-3219%281970%29040%3C0051%3ATGATPO%3E2.0.CO%3B2 15. Peck S, Peck L, Kataja M. Mandibular lateral incisor-canine transposition, concomitant dental anomalies, and genetic control. The Angle orthodontist 1998; 68(5),455-66. Avaliable from: http://www.angle.org/doi/pdf/10.1043/0003-3219%281998%29068%3C0455%3AMLICTC%3E2.3.CO%3B2

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16. Celikoglu M, Kazanci F, Miloglu O, Oztek O, Kamak H, Ceylan I. Frequency and characteristics of tooth agenesis among an orthodontic patient population.Med Oral Patol Oral Cir Bucal. 2010; 15(5), 797-801. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/20383097 17. Ambrosio AR, Shimizu RH, Ribeiro JS, Gomes AM, Machado AW. Avaliação da inclinação dos incisivos superiores e inferiores em indivíduos com maloclusão classe II, divisão 1, conforme o padrão facial. RSBO. 2009;6(4), 343-51.Avaliablefrom: http://www.redalyc.org/pdf/1530/153012921002.pdf 18. Wisth PJ, Thunold K, BoeOE. "The craniofacial morphology of individuals with hypodontia." Acta Odontol. Scand. 1974; 32(4), 281-90.Avaliablefrom: https://www.tandfonline.com/doi/abs/10.3109/00016357409026344 19. Zhu JF, Marcushamer M, King DL, Henry RJ. Supernumerary and congenitally absent teeth: a literature review. J ClinPediatr Dent. 1996; 20(2), 87-95. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/8619981 20. Freitas MRD, Souza LF, Janson GDRP, Henriques JFC, Sandrini EC. "Agenesias dentárias: relato de um caso clínico." Ortodontia. 1998; 31(1), 105-12. 21. Wagenberg BD, Spitzer DA. Therapy for a patient with oligodontia: case report. J eperiodontol.2000; 71(3), 510-16.Avaliable from: https://onlinelibrary.wiley.com/doi/abs/10.1902/jop.2000.71.3.510

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STUDY OF TITANIUM MESH IN ORBITAL FRACTURES - REVIEW OF LITERATURE

ESTUDIO DE LA MALLA DE TITANIO EN FRACTURAS ORBITALES - REVISIÓN

DE LA LITERATURA

ESTUDO DA MALHA DE TITÂNIO EM FRATURAS ORBITAIS - REVISÃO DA LITERATURA

Fabíola Frazão Lira1 1 - Center of Dental Specialties, City Hall of Aurora, CE, Brazil. Master of Science in Education. E-mail: biafrazao@hotmail.com

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Abstract Objective: To review the literature to analyze the means of diagnosis, treatment plans, complications and advantages of the use of titanic screens in the reconstruction of blow-out fractures. Materials and Methods: This is a review of the literature. The works were grouped for analysis considering the approaches prioritized in the period from 2010 to 2015. Results: The most effective diagnosis to detect blow out fractures is the clinical examination with the aid of computed tomography. In its planning it is necessary to use accessories like biomodelo or of intraoperative images or even prototypes for the reduction of postoperative sequels. The complications found in this type of fracture are: enophthalmos, zygomatic region, diplopia, ophthalmoplegia, distropia, infraorbital paraesthesia and amaurosis. Conclusion: The use of titanic mesh is a viable material of choice of treatment, presents advantages such as easy availability, three-dimensional elasticity, absence of reports on cytotoxicity. Keywords: Orbital Fracture; Titanium Mesh; Fracture of The Orbital Zygomatic Complex. Resumen Objetivo: Realizar una revisión de la literatura con el propósito de analizar los medios de diagnóstico, planes de tratamiento, complicaciones y ventajas del uso de las pantallas de titanio en la reconstitución de fracturas blow-out. Materiales y Métodos: Se trata de una revisión de la literatura. Los trabajos fueron agrupados para análisis considerando los enfoques priorizados en el período de 2010 a 2015. Resultados: El diagnóstico más efectivo para detectar las fracturas blow out es el examen clínico con el auxilio de la tomografía computarizada. En su planificación se deben utilizar accesorios como biomodelo o de imágenes intraoperatorias o incluso prototipos para la reducción de secuelas del postoperatorio. Las complicaciones encontradas en este tipo de fractura son: enoftalmia, hundimiento de la región zigomática, diplopía, oftalmoplejia, distropia, parestesia infraorbitaria y amauróse. Conclusión: El uso de la malla de titanio es un material viable de elección de tratamiento, presenta ventajas como fácil disponibilidad, elasticidad tridimensional, ausencia de relatos en cuanto a la citotoxicidad. Descriptores: Fractura Orbital; Malla de Titanio; Fractura del Complejo Zigomático Orbitario. Resumo Objetivo: Realizar uma revisão da literatura com o intuito de analisar os meios de diagnóstico, planos de tratamento, complicações e vantagensdo uso das telas de titânico na reconstituição de fraturas blow-out. Materiais e Métodos:Trata-se de uma revisão da literatura. Os trabalhos foram agrupados para análise considerando os enfoques priorizados no período de 2010 a 2015. Resultados: O diagnóstico mais efetivo para detectar as fraturas blow out é o exame clínico com o auxílio da tomografia computadorizada. Em seu planejamento deve-se utilizar acessórios como biomodelo ou de imagens intra-operatórias ou mesmo protótipos para a redução de sequelas do pós-operatório. As complicações encontradas neste tipo de fratura são: enoftalmia, afundamento da região zigomática, diplopia, oftalmoplegia, distropia, parestesia infraorbitária e amauróse.

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Conclusão: O uso da malha de titânico é um material viável de escolha de tratamento, apresenta vantagens como fácil disponibilidade, elasticidade tridimensional, ausência de relatos quanto à citotoxicidade. Descritores: Fratura Orbitária; Malha de Titânio; Fratura do Complexo Zigomático Orbitário. Introduction Orbital fractures or orbital floor lesions are a specific component of trauma presented in the middle third of the face and may present in isolation or associated with another bone structure and represent about 40% of craniofacial traumas. medial wall of the orbit are the most prone to fractures due to their thickness and bone size characteristics and their etiology is broad highlighting traffic accidents and physical aggressions.(1) Orbital floor injuries are also known as blow out fractures. This term was first recorded by Converse and Smith(2) in which they described fractures in the thin bones that make up the orbit. The term was used to describe those injuries whose orbital borders remained unchanged. Currently, it presents a pure and impure blow-out fracture denomination, defined by or not involving fractures in the surrounding structures of the cavity, such as the infraorbital border, zygoma and / or maxilla.(3-4) The pathophysiology of these fractures is explained by two theories. The first call of hydraulic theory reports that force is transmitted by impact on the eyeball, which undergoes retropropulsion and elevates intraorbital pressure. This pressure is transmitted to the medial or inferior wall, while the orbital border remains un-touched. The second theory is explained by the direct impact of the force on the orbital edge, where the force is transmitted to the wall of smaller thickness, causing the fracture.(5) The blow out fractures are characterized by the invasion of their contents into the maxillary sinus, which can cause diplopia, enophthalmia, motor dysfunction of the eyeball, as well as aesthetic deformities, directly influencing the social conviviality and the quality of life of the affected individuals. These fractures require effective treatment in order to avoid functional and aesthetic sequelae to patients.(6) The diagnosis of blowout fractures is based on physical examination and imaging. On physical examination, the following signs and symptoms can be observed: periorbital and subconjunctival ecchymosis, facial asymmetry, limitation of ocular movements, enophthalmia, emphysema, nasal bleeding, diplopia, infraorbital nerve paresthesia and visual acuity decrease(7) as well as aesthetic deformities, periorbital and/or subconjunctival ecchymosis, enophthalmia, orbital pain, infraorbital nerve paresthesia.(8) Diagnosis by the correlation of clinical and imaging diagnosis in which flat radiography is used through the posteroanterior and naso-naso incidence and computerized tomography (CT).(3,9-10) With this feature, it is possible to analyze the exact dimensions and locations of the diastases and the displacement of structural tissues from the orbit to the maxillary and ethmoidal sinuses and present the advantage of anticipating the institution of surgical treatment before the onset of sequelae such as enophthalmos.(3) In the literature different surgical methods are described, as well as various materials for orbital reconstruction, making it a difficult choice for the surgeon when it comes to the question of reconstruction. The existing biomaterials are presented in a natural and synthetic way and can be classified into alloplastics, grafts, autografts and grafts. Among the alloplastic materials the titanium screen is used as a routine

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feature in the treatment of orbital fractures and has shown a good success when used as a floor option in the repair of this type of fracture, due to its many advantages.11) According to Siveira et al.(6) the use of the titanium screen has shown effective results when treating blow-out and reliable fractures for the reconstruction of the floor, and presents as advantages its easy availability, dispensing use donor area reducing the morbidity of the procedure, modelable, short time fixation, adequate stiffness, low cytotoxicity and high biocompatibility. The titanium screen presents excellent rigidity, favoring the support of the structures contained in the orbit, but presents malleability, allowing several folds and/or adjustments to the complex contours of the orbit before its fixation with screws of small diameter, favoring its modeling to the complex contours of the and is easily attached with small diameter bolts. Another remarkable characteristic of titanium is that it is more compatible with the necessary post-operative examinations, such as computed tomography and magnetic resonance imaging.(6,12) However, the main disadvantage is the removal or recooling of the latter due to the strong adherence of the periodontal tissue to the mesh, in case there is a need for a second surgical intervention.(11) In view of this, it can be seen that the use of titanic mesh has been considered a material of wide choice when it comes to reconstituting blow-out traumas, but a recent survey in the literature is necessary, especially when related to cases with a considered level of follow-up time, to analyze the diagnostic means, treatment plans, complications and advantages of this type of biomaterial, in order to clarify and in making the safe and effective choice of the surgeon in order to reestablish the long-term health of their patients.

The aim of this study was to perform a literature review to analyze the means of

diagnosis, treatment plans, complications found and advantages of the use of titanic screens

in the reconstruction of blow-out fractures.The papers were grouped for analysis considering

the approaches prioritized in the period from 2010 to 2015.

Literature revision A review of the literature on the main texts on the subject was carried out, the

subjects discussed were analyzed in a qualitative way.(13-14) Silveira et al.(6) described a case report demonstrating the use of titanium mesh as an alternative treatment for orbital fractures. In the anamnesis the female patient, 33 years of age, presented polytrauma due to the automobile accident. He reported the presence of diplopia and cushioning of the left zygomatic region, enoitaria, loss of ocular mobility and esthetic defect, due to substantial loss of the zygomatic bone. Computed tomography showed the fracture of the left orbital floor. In the surgical procedure, the titanium mesh was used because of its immediate availability, with no need to remove the donor area, and due to its easy modeling and adequate stiffness to reach the necessary stability and after one year of case control, the patient presented no signal or symptom related to this type of fracture. Couto Júnioret al.(15) reported the treatment of sequelae of an orbital fracture forty days after the trauma with complaint of enophthalmos and diplopia. They perform the surgical treatment with infraorbital osteosynthesis with steel wire and reduction of herniation of the orbital content caused by the blow out fracture and

57

reconstruction of the right orbital floor with porous polyethylene and silicone sheet. In the postoperative period they observed alignment of the corneal reflexes and disappearance of the head's vicious position, but diplopia and enophthalmia had a slight improvement, which gave rise to the patient's late complaint. Tavares et al.(16) report in a clinical case of orbital fracture with complaint of right infraorbital paraesthesia, diplopia when looking downwards, through clinical and imaging examination, facial X-ray incidence Waters, with diagnosis of right floor fracture associated with fracture of the zygomatic body. As surgical surgical management they opted for the open approach with infraorbital access, reduction and containment with mini plates and screws in the zygoma body and titanium screen for reconstruction of the orbital floor. In the postoperative period, they observed no complications. They concluded that the diagnosis and planning are considerable factors in the choice of the best technique, in order to obtain a satisfactory, functional and aesthetic final result, according to the clinical and imaging exams. There is controversy between surgical and conservative treatment, although the tendency is surgical, in the form of exploration and repair, the access of choice depends not only on its advantages and disadvantages, but also on the surgeon's experience to perform it in the best way, without bring about damage to the patient, and what the defect size of the bone defect should always be taken into consideration, since small defects can be corrected with alloplastic material such as titanium mesh. Colombo et al.(5) reviewed the literature on the materials used to reconstruct trauma in the orbit. They reported that the main symptoms found due to a nonintervention or even an inadequate form can generate: enophthalmia, diplopia, ocular dystopia, restriction of ocular movement and infraorbital nerve dysfunction. For the effective diagnosis through multi-detector computerized tomography, three-dimensional analysis of the orbit was possible, as well as its volumetric evaluation, which revolutionized the surgical management of these fractures. Among the many materials used, it reports that titanium screens are widely accepted in the reconstruction of this type of fracture. This technology contributed to a precise anatomical correction, with long-term favorable results, with reduction of complications related to alteration of volume and orbital content, reducing the risk of enophthalmos. It has many advantages such as: excellent biocompatibility, good osseointegration. The screens are thin, allowing adjustment and molding with ease, to be adapted to the contour of the orbital floor and to promote efficient support of wide defects, low cost, radiopaques, allowing postoperative control, resistant to corrosion, sterilizable and with low infection rate. They also report that the meshes can be fixed by screws, preventing their displacement and migration, thus reducing the risk of extrusion and the need for removal, retained by the incorporation of fibrous and bone tissue around them. Among all these qualities and advantages it is still a frequently used material in surgical practice. One of the disadvantages is the risk of local inflammatory response, with formation of adhesions that may contribute to restriction of extrinsic ocular motility, but this is a minor complication reported. They also take into consideration that even before this, the choice of material should be based on the characteristics of the fractures, long-term results and experience of the surgeon. Rocha et al.(17) performed an image study of facial trauma with the objective of referencing the main types of face fractures, including nasal fractures, mandibular dislocations (Le Fort), orbital and maxillary zygomatic complexes, and on the findings of more relevant images in the therapy of these fractures. It reports that CT scans are

58

widely used in facial trauma, making it a safe method of choice in the evaluation of these patients, since it presents the ability of the compromised structures to be accurate, guiding the best therapeutic approach. Regarding the diagnosis and planning of cases, Vieiraet al.(18) used a biomodel made by the rapid prototyping method in a patient with a sequela from fractures of the orbital zygomatic complex caused by facial trauma with motorcycle accident etiology occurred ten years ago. This presented as symptoms to clinical findings facial asymmetry, left zygomatic flattening, enophthalmia and vertical distropia in the left orbit and complaint of diplopia. Still in the evaluation using the biomodel, they reported to have found a residual eyelid scar, due to the surgical access of the first surgery performed ten years ago, demonstrating the importance of the aid of this tool in the treatment of facial traumas to the bucomaxillofacial.Conclusion that the use of the biomodel was of great value for the surgical planning, since it can be measured with greater precision, providing improvement of results and reduction of surgical time, anesthesia and risk of infection. Mororó et al.(4) carried out a clinical case study of blow out fracture to discuss the aspects of this treatment. Male patient, 63 years of age, with facial asymmetry due to run over, with presence of edema, ecchymosis, mild dystopia and enophthalmos, and preserved ocular motility. A CT scan revealed an isolated fracture of the left orbital floor with herniation of the soft tissue into the maxillary sinus. In the surgical procedure, the titanium mesh was used and 24 hours after the procedure, there was no diplopia. In the postoperative period, after 7 months, the patient presented absence of all symptoms and a good positioning of the mesh. It concluded that the mesh is an option of choice for the treatment of blow out fractures, having the great support presented in the literature. Kersey et al.(19) performed a retrospective analysis of 10 cases at 2 centers in New Zealand, describing the complications related to the use of titanium screen orbital floor implants. Patients presented clinical symptoms such as diplopia or palpebral retraction after the repair of an orbital floor fracture with titanium mesh implants. It was pointed out that ten patients (7 males, 3 females) aged 15-78 years (mean age 39 years) presented significant restriction of eye movement and / or eyelid retraction after repairing an orbital floor fracture with an implant of titanium mesh. Seven patients had restricted eye movement alone. Three patients had less eyelid retraction, in addition to restriction of eye movement. One patient presented epiphora following erosion of the implant through the nasolacrimal canal. He also reported that seven patients underwent surgical removal of the implant with all patients showing improvement of postoperative extraocular circulation and that three cases were not submitted to removal of the implant with one case showing slight improvement over 9 months, and 2 cases showing no improvement. They concluded that the fibrous reaction between implant and orbital content caused restriction of eye movements and lid retraction and that the implant materials used in orbital floor fracture surgery should be inert with a flat profile, rather than a mesh with the intention of avoiding adhesions through the mesh that can cause scarring restriction of eye movement and eyelid retraction. Xuet al.(10) reported a retrospective analysis of 16 clinical cases of fractures and discussed the effectiveness, clinical features, and treatments for blow-out fractures. The image evaluation method used was computed tomography, in which it identified sites, degree, patterns and fracture characteristics. Among the 16 cases, 2 cases adopted conservative treatment; 11 cases gained a reduction in orbit fracture

59

through endoscopic surgery; the other 3 patients chose the endoscopic surgery and Caldw lell-Luc operations. Of the symptomatology presented, the diplopia was presented in a unanimous form and in 13 cases it was completely cured, the vision of 3 of the patients were significantly improved and 11 patients who presented 10 enophthalmia were healed. Among cases of ocular 15 movement disorder, the ocular movement of 13 patients was fully recovered. It was found that all patients' views were improved to varying degrees, and no one presented any complications. With this study, the authors concluded that computed tomography is useful for the diagnosis of simple blowoutorbital fracture. And that the operation of Caldwell-Luc with the transnasal endoscope is an effective method for the treatment of orbital fractures in these cases that presented diplopia. Another new instrument used in the evaluation of images for the study of orbital fractures is assisted virtual reconstruction. The objective of the study by Blumeret al.(20) was to evaluate if intraoperative images with virtual reconstruction assisted by computer would be advantageous in reconstructions of fractures orbital floor, evaluating a postoperative mirrored by computed tomography (CT), in which it was intraoperative closure, before wounds, during hospitalization and after hospitalization. We analyzed the agreement between evaluators and the game of intention to review and real review. Fifty-one anonymous postoperative CT scans of patients with a unilateral orbital floor fracture were mirrored using software. These computer-assisted virtual reconstructions were consecutively examined by 4 examiners. Seven of these patients underwent a review. In the first part, the agreements between evaluators were analyzed for all 3 times. In the second part, the intentions of the review reviewers were compared with the actual reviews performed. This study showed that out of 6 of 7 actual reviews, implant placement would have been reviewed intraoperatively by all 4 examiners if the images intraoperative with virtual reconstruction of the computer-assisted orbit would have been applied. Therefore, the authors suggest that intraoperative imaging with computer-assisted virtual reconstruction may be advantageous in preventing subsequent revisions of orbital floor fractures. In this study, the threshold for review of intraoperative implant placement appears to be lower when using intraoperative imaging with virtual reconstructions, because considerably more cases would have been reviewed intraoperatively by the examiners. In the hospital and post-hospital phases, this limit increased, suggesting that the most important role of clinical findings. It is uncertain whether the actual surgeons would have reviewed the same cases that the examiners had if they had used intraoperative imaging with virtual reconstructions for their deliberation. However, the agreement between intraoperative evaluators was good and costly postoperative reviews can be prevented. Limaet al.(21) performed a clinical study of a single male patient, 27 years old, in whom a pure blowout fracture was diagnosed after physical aggression. In a follow-up of 6 months of blow out fracture and use of the titanium mesh . The report describes the orbital wall region as the affected site without compromising the other bone structures. They report that the symptoms presented in this type of occurrence are: diplopia, paraesthesia of the infraorbital nerve, entrapment of soft tissue inside the maxillary sinus, limiting ocular movement and enoftlamia. Computed tomography was the method chosen to diagnose this fracture. After the surgical procedure, it was verified that no complication was presented and the patient was discharged after 1 day of the procedure. A new computed tomography scan was performed after surgery, showing a good adaptation of the titanium mesh. The patient remained

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under surveillance for six months, without complaint of paresthesia, visual disorders without signs or diplopia, demonstrating a satisfactory result. Albuquerque Neto et al.(22) reported in a pediatric patient clinical study after facial trauma with superior orbital rim fracture, and analyzed the importance of their clinical and imaging criteria. An 11-year-old male, victim of a sports accident presented a linear fracture of the upper orbital border. Four days after the trauma, he had fever, painful complaints in the left orbital area, pronounced ocular proptosis, palpebral ptosis, ophthalmoplegia, chemosis and decreased visual acuity caused by localized infection in the upper part of the orbit and muscle thickening due to edema. CT was performed, where hyperdensal images were observed in the left sinus spaces, thus suggesting that the infection affected the paranasal sinuses (ethmoidal and maxillary sinuses), which was consistent with the patient's chronic sinusitis history. diagnosis subperiosteal orbital abscess. Antibiotherapy was performed and after 3 days of invocation, the patient underwent surgery, with drainage of the maxillary sinus and immobilization of the fracture. in the postoperative period, patient presented decreased visual acuity due to edema. Ninety days after this evaluation, the patient presented without any symptoms, sequelae. They concluded that early diagnosis, through clinical and imaging findings, together with the appropriate surgical approach, are essential for the success and resolution of this type of infection. Discussion Many types of materials proposed on the market are proposed for the treatment of orbital fractures, among which we can mention the autogenous(23) allogeneic(9) and the alloplastic.(24) Such variability has been presented as a great difficulty to choose material for the dental surgeon or bucomaxillofacial surgeon. This choice is closely associated with the easy availability and biocompatibility of the material, the cost-benefit of each one, the previous planning of the case and the consistent reports presented in the literature.(5) Related to alloplastic materials, titanium meshes have shown great effectiveness when it comes to reconstruction of blow-out fractures,(4,6,16,21) as this showed a total or partial reduction with a decrease over the follow-up after the post-period of the symptoms presented, characteristic of this type of trauma. The symptoms that presented decrease or extinction were reported as enophthalmia, diplopia, ocular dystopia, restriction of ocular movement and dysfunction of the infraorbital nerve.(5-6,22) However, even with the great success of the use of the mesh, according to the literature, disadvantage as to the restraint of eye movements and the retraction of the cap, rather than the great adhesion of the mesh can cause scarring restriction of eye movement and eyelid retraction.(19) Another factor that contributes to the choice of material for the professional is the differential diagnosis of fracture and case planning. Current literature has shown that the most effective means of diagnosis is computerized tomography, which is able to identify the locations, degree, patterns and characteristics of orbital fractures, (10,20-21) and that it can also demonstrate hyperdense images in spaces which suggest outbreaks of infection.(22) The literature also reports that in conjunction with imaging exams, other technologies can be used such as virtual assisted reconstruction(20) to obtain favorable results in the postoperative period and higher in the professional, providing safety when using fracture reconstruction using the titanium meshes. Another

61

technology associated with the use of topography is the use of biomodelos when it deals with the importance of surgical planning. According to Vieiraet al.(18) the biomodels have the advantage of measuring with greater accuracy, which is capable of improving the results and reducing surgical time, anesthesia and risk of infection, considered to be extremely important factors for buccomaxillofacial in the surgical procedure. The literature has shown great support when it comes to the choice and use of the titanium mesh used in the surgical treatment of blow out orbital fractures due to its characteristics and advantages. This fact demonstrated a great safety in the choice from the professional, based on the reduction of the symptoms and an excellent prognosis according to the time approached in the postoperative period. However, this presents the disadvantage of epithelial adhesion to the mesh. In this way, additional studies are necessary to define new surgical protocols or even a possible modification in the structure of the mesh to avoid this adherence to the tissues, in order to minimize or extinguish such side effect. Conclusion Based on these considerations presented in this review, that the most effective diagnosis to detect blow out fractures is the clinical examination with the help of computed tomography; in its planning it is necessary to use accessories like biomodel or of intraoperative images or even prototypes for the reduction of postoperative sequels; that the complications found in this type of fracture are: enophthalmia, dip of the zygomatic region, diplopia, ophthalmoplegia, distropia, infraorbital paraesthesia and amauróse, it was concluded that the use of the titanic mesh is a viable material of choice of treatment taking into consideration the type of case, since it presents advantages such as easy availability, three-dimensional elasticity, lack of reports on cytotoxicity, and a simple and favorable option for reconstruction of this type of fracture. References 1. Nascimento LRXC. Incidência e Tratamento das Fraturas de Órbita no Hospital Municipal Lourenço Jorge – RJ. Rev. Bras. Cir. Bucomaxilofacial. 2010; 10(1), 7-12. 2. Converse JM, Smith B. Enophthalmos and diplopia: in Fractures Of The Orbital Floor. Br J Plast Surg. 1957; 9(4), 265-74.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/13396191 3. Souza EMRD, Rocha RS, Silva LCFD.Reconstruçãoorbitária com tela de titânio: relato de doiscasos. Rev. cir.traumatol. buco-maxilo-fac. 2009; 9(1), 75-82. Avaliable from: http://www.revistacirurgiabmf.com/2009/v9n1/10.pdf 4. Mororó ABG, Almeida S, Carvalho FSR, Freire Filho FW, Bezerra MF, Tavares RN. Tratamentocirúrgico de fraturaorbitária blow-out pura com tela de titânio: relato de casoclínico. Rev Odontol Bras Central.2013; 22(63), 120-3.Avaliable from: http://www.robrac.org.br/seer/index.php/ROBRAC/article/view/697/698 5. Colombo LRDC, Calderoni DR, Rosim ET, Passeri LA. Biomateriais para reconstrução da órbita: revisão da literatura. Rev. bras. cir.Plást. 2011; 26(2), 337-44.Avaliable from: http://www.scielo.br/pdf/rbcp/v26n2/a25v26n2.pdf 6. Silveira GR, Zardo M, Gonçalves RCG, Takahashi A. Uso de malha de titânio no tratamento de fraturas de assoalho de órbita: relato de caso. Innov Implant J, BiomaterEsthet. 2010 ; 5(3), 60-3. Avaliable from:

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http://revodonto.bvsalud.org/pdf/iij/v5n3/a12v5n3.pdf 7. Swinson B, Amin M, Nair P, Lloyd T, Ayliffe P. Isolated bilateral orbital floor fractures: a series of 3 cases. J. oral maxillofac.surg. 2004; 62(11), 1431-5.Avaliable from: https://www.joms.org/article/S0278-2391(04)01041-9/pdf 8. Bourguignon Filho AM, Costa TA, Hibrahim D, Blaya DS, Viegas VN, Oliveira MG. FraturasorbitáriaBlo- wout: tratamento com telas de Titanio. Rev. Cir. Traumatol. Buco-Maxilo-Fac. 2005; 5(3), 35-42. Avaliable from: http://www.revistacirurgiabmf.com/2005/v5n3/pdf%20v5n3/v5n3.4.pdf 9. Ellis III, Tan YE. Assessment of internal orbital reconstructions for pure blowout fractures: cranial bone grafts versus titanium mesh. J. oral maxillofac.surg. 2003; 61(4), 442-53.Avaliable from: https://www.sciencedirect.com/science/article/pii/S0278239102157144 10. Xu W, Zhao C, Jin L, Ge R. Clinical analysis of simple orbital blowout fracture. Lin chuanger bi yanhoutoujingwaikezazhi.Journal of clinical otorhinolaryngology, head, and neck surgery.2015; 29(5), 418-21.Avaliable from: https://europepmc.org/abstract/med/26103660 11. González E, Pedemonte C, Vargas I, Verdugo-Avello F. EvaluaciónClínica de la ReconstrucciónOrbitaria Post Traumática Mediante Mallas de Titanio. Rev Chil Cir. 2015; 67(3), 252-8.Avaliable from: https://scielo.conicyt.cl/pdf/rchcir/v67n3/art03.pdf 12. Park HS, Kim YK, Yoon CH. Various aplications of titanium mesh screen to orbital wall fractures. J Craniofac Surg. 2001;12(6), 555-60. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/11711822 13. Mesquita RF, Matos FRN.Aabordagemqualitativanasciênciasadministrativas: aspectoshistóricos, tipologias e perspectivasfuturas. RevistaBrasileira de AdministraçãoCientífica. 2014; 5(1), 7-22.Avaliable from: http://sustenere.co/journals/index.php/rbadm/article/view/SPC2179-684X.2014.001.0001/478 14. Sousa LRM. Prevenção e tratamento de úlcerasporpressão: análise de literaturabrasileira. Rev Enferm UFPI.. 2015; 4(3), 79-85.Avaliable from: http://www.ojs.ufpi.br/index.php/reufpi/article/view/1983/pdf 15. Couto Júnior AS, Oliveira DA, Mattosinho CCS, Curi R. Fratura de ÓrbitaporQueda de Cavalo e Correção de Estrabismo. Rev. Bras. Oftalmol.2010; 69 (3), 180-3.Avaliable from: http://www.scielo.br/pdf/rbof/v69n3/a08v69n3.pdf 16. Tavares SSS, Tavares GR, Oka SC, Cavalcante JR, Paiva MAF.FraturasOrbitárias: Revisão de LiteraturaemRelato de Caso. Rev. Bras. de Cir. Bucomaxilofacial. 2011; 11(2);, 35-42. Avaliable from: http://www.itarget.com.br/newclients/bucomaxilo.org.br/2010/extra/down/revistas/artrev_04.pdf 17. Rocha NSM, Andrade JR, Jayanthi SK. Imagem no Trauma de Face. Rev. Med. 2011; 90(4), 169-73.Avaliable from: http://www.revistas.usp.br/revistadc/article/view/58921/61899 18. Vieira WM, Schneider LP, Siqueira OV.CorreçãoCirúrgicaSecundária do ComplexoZigomáticoOrbitário com Auxílio de Biomodelo de PrototipagemRápida. Rev. Bras. Cir. Crâniomaxilofacial. 2012; 15(3), 152-4.Avaliable from: http://www.abccmf.org.br/cmf/Revi/2012/julho-setembro/10-Corre%C3%A7%C3%A3o%20cir%C3%BArgica%20secund%C3%A1ria%20do%20complexo%20zigomatico.pdf 19. Kersey TL, Ng SG, Rosser P, Sloan B, Hart R.. Orbital adherence with titanium mesh floor implants: a review of 10 cases. Orbit. 2013; 32(1), 8-11. Avaliable from:

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https://www.tandfonline.com/doi/abs/10.3109/01676830.2012.736597 20. Blumer M, Gander T, Gujer AK, Seifert B, Rücker M, Lübbers HT. Influence of Mirrored Computed Tomograms on Decision-Making for Revising Surgically Treated Orbital Floor Fractures. J Oral Maxillofac Surg. 2015; 73(10), 1982-e1- 9.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/26172991 21. Lima LB, Miranda RBM, Furtado LM, Rocha FS, Silva MCP, Silva CJ. Reconstruction of orbital floor for treatment of a pure blowout fracture.rev port estomatol med dent cir maxi lofac. 2015; 56(2), 122-6.Avaliable from: http://www.elsevier.pt/en/revistas/revista-portuguesa-estomatologia-medicina-dentaria-e-cirurgia-maxilofacial-330/pdf/S1646289015000448/S300/ 22. Albuquerque Neto ADD, Sampaio TRDC, Cavalcante DKF, NogueiraFilho LLT, Nogueira PTBDC, LaureanoFilho JR. Surgical approach of orbitalsubperiosteal abscess associated with the orbital fracture. Rev. bras.oftalmol. 2015; 74(5), 315-8.Avaliable from: http://www.scielo.br/pdf/rbof/v74n5/0034-7280-rbof-74-05-0315.pdf 23. Kontio R. Treatment of orbital fractures: the case for reconstruction with autogenous bone. J Oral Maxillofac Surg. 2004; 62(7), 863-8.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/15218567 24. Schön R, Metzger MC, Zizelmann C, Weyer N, Schmelzeisen R. Indi- vidually preformed titanium mesh implants for a true-to-original repair of orbital fractures. Int J Oral Maxillofac Surg. 2006; 35(11), 990-5.Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/17049812

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CLEANING OF THE ISTMO REGION WITH ULTRASOUND ACTIVATION IN LOWER MOLARS - COMPARATIVE ANALYSIS "EX VIVO"

LIMPIEZA DE LA REGIÓN DE ISTMO CON ACTIVACIÓN ULTRASÓNICA EN

MOLARES INFERIORES- ANÁLISIS COMPARATIVO "EX VIVO"

LIMPEZA DA REGIÃO DE ISTMO COM ATIVAÇÃO ULTRASSÔNICA EM MOLARES INFERIORES- ANÁLISE COMPARATIVA “EX VIVO”

Marcus Victor Vaz Soares Castro1, Brunna da Silva Firmino2, Humbelina Alves da Silva3, Lara Lysle Silva dos Santos4, Maria Ângela Arêa Leão Ferraz5, Rodrigo Barcelos Barbosa6, Rebeca Maria Vieira Pereira7, Wanderson Carvalho de Almeida8, Carlos Alberto Monteiro Falcão9 1 – Universidade Estadual do Piauí – UESPI, Undergraduate Student in Dentistry. E-mail: m_vvaz@hotmail.com 2 – Universidade Estadual do Piauí – UESPI, Undergraduate Student in Dentistry. E-mail: bfirminno@gmail.com 3 – Universidade Estadual do Piauí – UESPI, Undergraduate tudent in Dentistry. E-mail: humbelinaalves@gmail.com 4 – Universidade Estadual do Piauí – UESPI, Dentist. E-mail: lara_lysle@hotmail.com 5 – Universidade Estadual do Piauí – UESPI, PhD in Endodontics. E-mail: angela.endo@hotmail.com 6 – Universidade Estadual do Piauí – UESPI, Undergraduate Student in Dentistry. E-mail: rodrigo_bbb@hotmail.com 7 – Universidade Estadual do Piauí – UESPI, Undergraduate Student in Dentistry. E-mail: rebecamaryya@hotmail.com 8 – Universidade Estadual do Piauí – UESPI, Undergraduate Student in Dentistry. E-mail: wandstron@gmail.com 9 – Universidade Estadual do Piauí – UESPI, PhD in Dental Clinics. E-mail: falcaoendo@hotmail.com

Marcus Victor Vaz Soares Castro (Corresponding author) Undergraduate in Dentistry, Undergraduate Student at Universidade Estadual do Piauí – UESPI, m_vvaz@hotmail.com

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Abstract Objective: To observe the degree of penetration of the obturator cement in the isthmus region of mesial roots of lower molars after ultrasound use. Materials and Methods: 30 extracted human lower molars were used. The teeth were instrumented and randomly divided into three groups which used different smear layer removal techniques. The results were submitted to statistical analysis by the Mann-Whitney test. Results: It was observed that the use of ultrasound with specific insert for isthmus cleaning did not influence the degree of penetration of endodontic cementum in the cervical and middle thirds of the root canals. Conclusion: The use of ultrasound in the final toillet of root canals influenced root canal cleansing when compared to manual technique. Keywords: Endodontics; Ultrasonics; Root Canal Obturation. Resumen Objetivo: Observar el grado de penetración del cemento obturador en la región de istmos de raíces mesiales de molares inferiores después del uso del ultrasonido. Materiales y Métodos: Se utilizaron 30 molares inferiores humanos extraídos. Los dientes fueron instrumentados y divididos aleatoriamente en tres grupos los cuales utilizaron técnicas distintas de remoción de smear layer. Los resultados fueron sometidos a análisis estadístico por el test Mann-Whitney. Resultados: Se observó que la utilización de ultrasonido con inserto específico para limpieza de istmo no influenció en el grado de penetración del cemento endodóntico en los tercios cervical y medio de los canales radiculares. Conclusión: La utilización del ultrasonido en la toillet final de los canales radiculares influenció en la limpieza de los canales radiculares en comparación con la técnica manual. Palabras-Clave: Endodoncia; Ultrasonido; Obturación del Conducto Radicular. Resumo Objetivo: Observar o grau de penetração do cimento obturador na região de istmos de raízes mesiais de molares inferiores após utilização do ultrassom. Materiais e Métodos: Foram utilizados 30 molares inferiores humanos extraídos. Os dentes foram instrumentados e divididos aleatoriamente em três grupos os quais utilizaram técnicas distintas de remoção de smear layer. Os resultados foram submetidos a análise estatística pelo teste Mann-Whitney. Resultados: Observou-se que a utilização de ultrassom com inserto específico para limpeza de istmo não influenciou no grau de penetração do cimento endodôntico nos terços cervical e médio do canais radiculares. Conclusão: A utilização do ultrassom na toillet final dos canais radiculares influenciou na limpeza dos canais radiculares quando comparado com a técnica manual. Descritores: Endodontia; Ultrassom; Obturação do Canal Radicular. Introduction

Success in endodontic therapy is based on the degree of knowledge of the morphology and anatomical complications of root canals, such as accessory canals, apical deltas and the presence of isthmuses. These are defined as a flat space that can promote partial or total communication between the channels of the same root.(1)

66

The instrumentation of this root canal system generates a waste layer composed of an amorphous, irregular and granular substrate with tissue remains, organic matter, inorganic matter and microorganisms adhered to the canal walls, obstructing the dentinal tubules and creating an interface between the material obturator and dentin. This reduces the root permeability, requiring the use of auxiliary chemical substances that act on organic and inorganic matter.(2)

The applicability of irrigation in endodontic treatment is to promote the removal of pulp tissue, microorganisms, when present, remove dentine residues, as well as neutralize bacterial toxic products and lubricate the walls of the conduits.(3)

The anatomical variations are an important factor to be considered, since the cleaning of curved, narrow and flattened ducts is not always easily performed. The agitation that the ultrasound promotes, provides that the irrigantes circulate in areas of anatomical complexity.(4-5)

The irrigators most commonly used in endodontic treatment are sodium hypochlorite (NaOCl) and chlorhexidine, due to their antimicrobial activities, but because of their inability to effectively remove the smear layer, the use of ethylenediaminetetraacetic acid (EDTA) is necessary. allows the removal of the smear layer, however, it has been observed that none of these solutions completely removes the dentin mud, especially when it is not associated with a type of activation.(6)

Considering the small diameter of the canal, its ramifications and anatomical irregularities, the irrigant may find it difficult to cover the entire region of the canal. Several studies have proposed the use of the ultrasonic activation of the irrigant to improve its action, being of great relevance for cleaning regions of complex anatomy. (7)

The apical cleaning of flat root canals instrumented through manual and rotational techniques associated with ultrasonic irrigation using 6% sodium hypochlorite presents satisfactory results in cleaning root canal walls and isthmus. The use of an irrigation needle coupled to the ultrasound as a guarantee of the constant renewal of the irrigating solution during the ultrasonic activation favors the cleaning.(8)

In order to evaluate the effect of EDTA 17% with and without the passive use of ultrasound in the ability to remove the smear layer, the researchers established a final irrigation protocol, after biomechanical preparation, for the four groups in which EDTA was used 17% as follows: the first group was irrigated with 17% EDTA for 3 minutes, the second group underwent ultrasonic irrigation with 17% EDTA for 3 minutes. In the other two groups the time of EDTA use was only reduced from 17% from 3 minutes to 1 minute. With the aid of M.E.V, the authors evaluated the removal of the smear layer from the specimens and concluded that the groups that used passive ultrasonic irrigation had a significant difference in the removal of these debris in relation to the groups that the ultrasound was not used. It was also observed that 1 minute of ultrasonic irrigation with EDTA 17% is enough for the removal of the dentin mud in the apical third of the root canal.(9)

In a study evaluating the effectiveness of saline solutions, NaOCl 2.5% and Chlorhexidine 2% with and without passive ultrasonic irrigation for the removal of debris from simulated irregularities in the apical third of the root canals, bovine lateral incisors were included in muffle with silicone and the channels prepared with oscillatory system up to a diameter of 80, irrigated during preparation with 2.5% NaOCl (groups 1 and 2) and with 2% chlorhexidine (group 3). After the preparation, the roots were sectioned longitudinally. The post-experiment images were obtained

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by scanning electron microscopy with 20x magnification. The authors verified that, regardless of the irrigation solution used, passive ultrasonic irrigation makes the removal of debris from the apical third more effective, however, it did not obtain complete cleaning in any sample.(10)

In an in vitro comparison on the incidence and type of isthmus, in the first molars, 72 teeth with intact roots and not endodontically treated were used. With their crowns removed the specimens were included in silicone mold and wrapped in epoxy resin and then sectioned perpendicular to their long axis, the sections produced were stained and analyzed under microscopy for the presence and type of isthmus based on the classification of Hsu & Kim. The observed results point to a higher prevalence of this anatomical structure in more cervical levels, having in the lower molars a percentage of 100% incidence in the two most coronal cuts, and being in the great majority of the type that has the union between two separated ducts carried out by the isthmus.(1)

The present study evaluated the degree of penetration of the obturator cement in the isthmus regions of the root canal after using ultrasound with specific inserts, in comparison with other techniques that do not use it.

Material and Method

This is a study with a quantitative and experimental approach, and its

development in the Preclinical laboratory of the School of Dentistry of the State University of Piauí - UESPI, Campus Alexandre Alves de Oliveira, and the results evaluated in the Institutions dependencies.

Thirty human teeth (lower molars) were selected with intact roots and fully formed apices obtained from the teeth bank of the State University of Piauí -OSPI, submitted to sterilization in autoclave and preserved in saline solution at room temperature until the moment of the experiment.

Soon after the start of the sectioning and elimination of the dental crowns with double-faced diamond disc (KG Sorensen®, Cotia, São Paulo, Brazil) mounted in low rotation with the purpose of facilitating the instrumentation of the channels. Odontometry was performed with a K-file file (Dentsply® Maillefer, Petrópolis, Rio de Janeiro, Brazil) #15 until reaching the apical foramen and retreating 1mm in order to obtain the working length.

The teeth were randomly divided into 3 groups with 10 specimens each, where all were submitted to the same biomechanical preparation using instruments of the Reciproc R25 Non-Reciprocal Oscillatory System (VDW, Germany) , with the aid of a 1% sodium hypochlorite solution (Biodinâmica®, Ibiporã, Paraná, Brazil), aspiration and drying by means of a metal vacuum cannula (Endo Points®, Rio de Janeiro, Rio de Janeiro, Brazil) and cones of absorbent paper Reciproc R25 (VDW, Germany).

Always irrigate with 1% sodium hypochlorite. After instrumentation and drying of the channel, the final toillet stage was performed, followed by obturation according to the following approaches as expressed in Table 1: Table 1 - Distribution of the groups according to the channel system cleaning method.

Groups Amount of specimens

Technique

Group 1 (control)

10 Instrumentation, EDTA sludge removal activated with

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memory instrument for 5 minutes, single cone technique

Group 2 10 Instrumentation, removal of dentin sludge with EDTA activated with ultrasound for 30 seconds, single cone technique.

Group 3 10 Instrumentation, isthmus cleaning with ultrasonic activation, removal of the dentin sludge with EDTA activated with ultrasound for 30 seconds, single cone technique

Total 30 -

Ultrasonic activation was performed using the E18 Istmo and E1 (Irrisonic)

Helse inserts coupled to the CVDentus Ultrasound device, at a power of 10% as indicated by the manufacturer.

After the final toillet and drying of the conduits, the canals were sealed by the single cone technique, in which Sealer 26 cement (Dentsply®, Petrópolis, Rio de Janeiro, Brazil) was fed to the canal through a lentullo # 01 drill bit (Dentsply® , Petrópolis, Rio de Janeiro, Brazil), followed by the placement of the gutta-percha cone of the Reciproc System, R 25 (VDW, Germany). Excesses were removed with heated condenser (Dentsply, Petrópolis, Rio de Janeiro, Brazil), followed by cold vertical condensation. The entrance of the channels was sealed with TPH Spectrum photopolymerizable composite resin (Dentsply®, Petrópolis, Rio de Janeiro, Brazil) and the roots radiographed.

After 72 hours, the teeth were sectioned using a diamond disk (KG Sorensen®, Cotia, São Paulo, Brazil) in two transversal planes (one in the cervical third and the other in the middle third) and made a wear of this thickness of 1mm to visualize (KG Sorensen®, Cotia, São Paulo, Brazil), medium grain size.

For the evaluation of cross-sectional plans, an Operative microscope (DFVasconcellos®, Valença, Spain) was used. The results were classified in four modalities, regarding the penetration level of the obturator material in the isthmus region, these being: Degree 0 - there was no filling of the isthmus region. Grade 1- when there was penetration up to 1/3 of the isthmus region. Grade 2- when penetration covered the middle third of the isthmus. Degree 3 - Full isthmus penetration.

The research was approved by the Research Ethics Committee of FACIME/UESPI, under number 1,801,895. Results

SPSS, in its version 21, was used to perform comparative analyzes between

groups with small samples. For that, Kruskal-Wallis ANOVA was calculated, followed by Mann-Whitney tests.

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Table 2 - Distribution of the samples according to the degree of penetration of the cement observed at 03 mm from the apex.

Groups Grade 0 (without

penetration)

Grade 1 (penetration up

to 2/4 of the isthmus region)

Grade 2 (penetration

close to 4/5 of the isthmus

region)

Grade 3 (total

penetration of the

isthmus region)

1 2 2 2 4 2 0 1 0 9 3 2 1 2 5

Source: Direct Search From the sample, Kruskal-Wallis ANOVA test was performed of one factor in

the three groups analyzed at 3 mm from the apex. It was observed that there was no statistical difference between the means of the groups. However, it can be observed that group II had the highest mean and group I had the lowest mean. From the results, χ 2 (chi-square) of 5.22 was observed, with an associated probability of 0.07. Thus, the difference was close to being statistically significant as compared to the other groups.

It was also sought to complement these results by performing, through the Mann-Whitney test, the comparison between the groups, according to Table 3, demonstrating the statistically significant difference between G1 x G2; marginally between G2 x G3 and non-statistically significant G1 x G3. Table 3 - Comparisons between the groups at 3 mm from the apex (from the Mann-Whitney test).

Comparative Samples (two to two)

Difference between averages

Meaningfulness

Group 1 X Group 2 5,0 0,03* Group 1 X Group 3 1,0 0,70 Group 2 X Group 3 4,0 0,06

Source: Direct Search Note: * p <0.05 (significant) Table 4 - Distribution of the samples according to the degree of penetration of the cement observed at 06 millimeters from the apex.

Groups Grade 0 (without

penetration)

Grade 1 (penetration up

to 2/4 of the isthmus region)

Grade 2 (penetration

close to 4/5 of the isthmus

region)

Grade 3 (total

penetration of the

isthmus region)

1 5 0 0 5 2 0 1 4 5 3 2 2 1 5

Source: Direct Search The Kruskal-Wallis ANOVA test was performed with one factor in all three

groups. The projection for the mean of the stations for each of the groups can be

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observed at 06 mm from the apex. The results presented a χ² (chi-square) of 2.47 with an associated probability of 0.52.

Therefore, there was no statistically significant difference in penetration observed in each group. It was observed that in both conventional and ultrasound cleaning techniques good hygiene indices were obtained in the cervical and middle thirds, which may be justified by the amplitude of these regions. We also sought to complement these results by performing a Mann-Whitney test comparing the groups, according to Table 5, showing that there was no statistically significant difference between G1 x G2; G1 x G3; G2 x G3. Table 5 - Comparisons between the groups at 06 mm from the apex (from the Mann-Whitney test).

Comparative Samples (two to two)

Difference between averages

Meaningfulness

Group 1 X Group 2 2,50 0,50 Group 1 X Group 3 1,50 0,53 Group 2 X Group 3 1,70 0,49

Source: Direct Search. Note: * p <0.05 (significant) Discussion

The isthmus observed in the dental roots represents a complex anatomical structure. Researches that suggest that most of these structures present an obliteration in the communication between the ducts, by apposition of dentin, and therefore need sanification that transposes this difficulty.(1)

Studies also demonstrate that the root isthmus, because of its unpredictable location and anatomically complex, makes cleaning and disinfection laborious, where conventional instrumentation does not have the capacity to reach all irregularities. Irrigating substances play an important role in the debridement of the unreached residues, however the regions of greater complexity still present resistance to the penetration of these irrigants.(11-12)

Activation with ultrasound provides the transmission of acoustic micro current energy generating a greater agitation of the irrigators, which results in the penetration of the material into areas of anatomical complexity and tubules producing a greater capacity of cleaning.(5)

Ultrasound is considered an alternative to minimize the difficulties of sanitizing the conduit system, since it is observed that the agitation promoted by its action provides that the irrigators circulate in areas of anatomical complexity resulting in greater cleaning capacity, obtaining satisfactory results in the hygiene of the root walls and isthmus.(5-8)

Passive ultrasonic irrigation presents more favorable results regarding the degree of cleaning compared to other techniques that do not use ultrasound.(8-9,13-14)

The present study used similar results when it observed a greater penetration of endodontic cement in the isthmus region when the passive ultrasonic activation was used.

The cleaning effectiveness conferred by ultrasonic irrigation was more pronounced in apical third,(10) as can be observed in the experiment, in which the significant difference was found in the evaluation of the cuts at the apex 3mm level.

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The use of the special insert for the cleaning of the isthmus region did not change the result regarding the penetration of the sealant cement when compared to the techniques that did not use this feature. This result can be justified, since the recommended insert for isthmus cleaning only acts on the cervical and middle third, which are of greater amplitude, where the efficient action of conventional techniques is observed.

Despite the results obtained in the present study, it was observed that the protocol of use of the ultrasonic inserts for isthmus cleaning and removal of the smear layer used reduced time with similar or superior results to the conventional techniques, reducing the operative time. Conclusion

It was concluded that the use of ultrasound with specific insert for isthmus

cleaning did not influence degree of penetration of the endodontic cement in the isthmus region. The use of ultrasound in the final toillet of the root canals helps in the removal of the dentinal mud in the apical and middle thirds of the root canals. References 1. Oliva RR, Gastélum ZAG, Hernández MY, Mariel CJ, Gutiérrez CFJ. Incidencia y Tipo de Istmos en Primeros Molares Permanentes Humanos, Evaluación in vitro. Int. J. Morphol. 2017; 35(4), 1280-4. Avaliable from: https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0717-95022017000401280 2. Hulsmänn M, Rümmelin C, Schäfers F. Root Canal Cleanliness After Preparation with Different Endodontic Handpieces and Hand Instruments: A Comparative SEM Investigation. J Endod. 1997; 23(5), 301-306. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/9545932 3. Van der Sluis LWM, Vogels MPJM, Verbaagen B, Macedo RDDS, Wesselink PR. Study on the Influence of Refreshment/Activation Cycles and Irrigants on Mechanical Cleaning Efficiency During Ultrasonic Activation of the Irrigant. J Endod. 2010; 36(4), 737-40. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/20307755 4. Barbizam JVB, Fariniuk LF, Marchesan MA, Pecora JD, Sousa-Neto MD. Effectiveness of Manual and Rotary Instrumentation Techniques for Cleaning Flattened Root Canals. J Endod. 2002; 28(5), 365-6. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/12026920 5. Guimarães BM, Amoroso-Silva PA, Alcalde MP, Marciano MA, de Andrade FB, Duarte MA. Influence of ultrasonic activation of 4 root canal sealers on the filling quality. J Endod. 2014; 40(7), 964-8. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/24935544 6. Poletto D, Poletto AC, Cavalaro A, Machado R, Cosme-Silva L, Garbelini CCD, et al. Smear layer removal by different chemical solutions used with or without ultrasonic activation after post preparation. Restor Dent Endod. 2017; 42(4), 324-31. Avaliable from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682149/ 7. Gründling GL, Zechin JG, Jardim WM, Oliveira SD, Figueiredo JAP. Effect of Ultrasonics on Enterococcus faecalis Biofilm in a Bovine Tooth Model. J Endod. 2011; 37(8), 1128-33. Avaliable from:

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https://www.ncbi.nlm.nih.gov/pubmed/21763907 8. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary instrumentation in human mandibular molars. J Endod. 2005; 31(3), 166-70. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/15735461 9. Kuah HG, Lui JN, Tseng PS, Chen NN. The effect of EDTA with and without ultrasonics on removal of the smear layer. J Endod. 2009; 35(3), 393-6. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/19249602 10. Justo AM, Rosa RA, Santini MF, Ferreira MBC, Pereira JR, Duarte MAH, et al. Effectiveness of Final Irrigant Protocols for Debris Removal from Simulated Canal Irregularities. J Endod. 2014; 40(12), 2009-14. Avaliable from: https://www.sciencedirect.com/science/article/pii/S0099239914007882 11. Estrela C, Rabelo LE, de Souza JB, Alencar AH, Estrela CR, Sousa Neto MD, et al. Frequency of Root Canal Isthmi in Human Permanent Teeth Determined by Cone-beam Computed Tomography. J Endod. 2015; 41(9), 1535-9. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/26187423 12. Adcock JM, Sidow SJ, Looney SW, Liu Y, McNally K, Lindsey K, et al. Histologic evaluation of canal and isthmus debridement efficacies of two different irrigant delivery techniques in a closed system. J Endod. 2011; 37(4), 544-8. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/21419306 13. Guerisoli DM, Marchesan MA, Walmsley AD, Lumley PJ, Pecora JD. Evaluation of smear layer removal by EDTAC and sodium hypochlorite with ultrasonic agitation. Int Endod J. 2002; 35(5), 418-21. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/12059911 14. Castagna F, Rizzon P, Rosa RA, Santini MF, Barreto MS, Duarte MAH, et al. Effect of Passive Ultrassonic Instrumentation as a Final Irrigation Protocol on Debris and Smear Layer Removal—A SEM Analysis. Microsc Res Tech. 2013; 76 496-502. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/23456772

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ELIMINATION OF ABUSIVE USE OF MEDICINES IN THE CONTROL OF OROFACIAL PAIN

ELIMINACIÓN DEL USO ABUSIVO DE MEDICAMENTOS EN EL CONTROL DEL

DOLOR OROFACIAL

ELIMINAÇÃO DO USO ABUSIVO DE MEDICAMENTOS NO CONTROLE DA DOR OROFACIAL

Livio Portela de Deus Lages1, Lorenzo Benetti Maia2 1 – São Leopoldo Mandic Research Center. E-mail: liviolages@uninovafapi.edu.br 2 – Universidade Vale do Rio Doce, Dentist. E-mail: lorenzobenetti01@gmail.com

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Introduction

Muscular and articular temporomandibular disorders (TMD) are the second most frequent condition of musculoskeletal pain, less frequent only than pain in the lower back. Approximately 5 to 12 percent of the US population is affected by TMD.(1)

During the last decade, there has been a substantial increase in the use of drugs prescribed for the treatment of patients with chronic pain. In addition to opioids, several other analgesic and non-analgesic drugs, including antidepressants, anxiolytics / sedatives, anticonvulsants, muscle relaxants, and non-steroidal anti-inflammatory drugs (NSAIDs) are often prescribed simultaneously to patients. Despite the potential benefits of each of these drugs for the treatment of patients with pain, it is well known that the combination of a wide variety of drugs can lead to a number of adverse side effects, including nausea, dizziness, headaches, and weakness. These drug side effects are often observed in clinical settings, and represent a complex issue of pain management.(2)

With the sharp increase in prescription of opioids to treat chronic pain(3-4) there has been a concomitant increase in concern about the risk of abuse of opioid prescription, the prevalence of non-medical use of opioids in the US is large.(5)

The concomitant use of opioids, benzodiazepines, and/or alcohol presents a formidable challenge for clinicians controlling chronic pain. While the increasing use of opioid analgesics for the treatment of chronic pain increases concomitantly to abuse related to opioids and their misuse are widely recognized, such as the contribution of the use of combined benzodiazepines, alcohol, and/or other sedative agents to related morbidity to the opioid and mortality is underestimated, even when these agents are used properly. Patients with chronic pain using opioid analgesics along with benzodiazepines and / or alcohol are at greater risk of fatal overdose or non-fatal and have more aberrant behaviors.(6)

The purpose of this case report is to describe the elimination of abusive medication use in the control of orofacial pain and temporomandibular disorders associated with different therapies. Case report

The patient R.A.M., male, 35 years old, attended the Clinic of Temporomandibular Disorders and Orofacial Pain of the Center of Dental Research of São Leopoldo Mandic, with main complaint of Pain in the left and right maxillary, 18 months ago.

On the RDC / TMD, pain in the bilateral masseteric parotid region, intensity 5, pressure type, was daily, started in the morning or in the afternoon and remained until bedtime.

Improvement factor: Torsilax (30 tablets per month, one year ago); Nimesulide (12 tablets per month). Comorbidity: cervicalgia. It was also verified, Pain in the bilateral pre-auricular region, intensity 8, throbbing type, twice a week, started in the afternoon and remained until bedtime. Accompanying factor: clicks.

Improvement factor: Nimesulide (16 tablets per month); Ibuprofen (24 tablets per month); Codeine + Paracetamol (8 tablets per month). In addition to Midazolam (02 tablets per day) to sleep; Citalopram (01 tablet daily) for depression; Lorazepam (1 tablet daily).

He presented as habits: onicofagia, pen leaning on the mouth, two pillows and wrong posture to sleep. He reported Bruxism in wakefulness. Introduced Trigger

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Point in the Masseter, Trapezium and Suboccipitals. Diagnosis: Muscular DTM with comorbidity: Cervicalgia.

Therapeutic Therapies used: Thermotherapy, Stretching cervical muscles and masticators, Transcutaneous electrical stimulation (TENS), Exercises, Behavioral Cognitive Therapy, Dry Needling and was demanded the elimination of excessive use of medicines used for the purpose of pain relief.

Four therapeutic sessions were performed. At the fourth session, the patient

reported a significant improvement and stated that he was not taking any other medication. Discussion

The literature demonstrates that the misuse and abuse of drugs in the pharmacological control of TMD may be the cause of some concern. Care should be taken to ensure that patients with chronic pain do not take too much medication for long periods of time and become dependent on analgesic drugs. Drug dependence in "patients with pain" usually involves primary headache syndromes with chronicity resulting from the combination of analgesic and / or psychotropic, containing or not ergotamine. Since, during the withdrawal phase, increased pain intensity in conjunction with other withdrawal phenomena is expected, in some cases hospitalization may be indicated. Psychosomatic pain syndromes with benzodiazepine dependence represent the second largest group.(7)

In the case cited, the patient presented a clinical picture of myofacial pain, chronified by drug abuse, with a large number of non-steroidal analgesics (NSAIDs), combined with opioid analgesics and some benzodiazepines. According to the

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literature, during the phase of drug elimination, an increase in pain intensity was expected in conjunction with other withdrawal symptoms, and other alternatives for pain elimination were indicated to the patient.

Because of the pains, mostly of muscular origin, the patient was instructed to perform thermotherapy for 20 minutes and exercises daily for 3 times, and whenever he had pain crises. Heat treatment showed benefits such as pain relief, reduced muscle tension, improved jaw function and increased mouth opening, which justifies the clinical use of this technique in TMD therapy.(8) In addition to the recommendations to be performed daily at home, 4 sessions were also conducted where, in addition to behavioral cognitive orientations, TENS and dry needling sessions were performed, which according to Unverzagt(9) is a well-established technique in medical science that can be used to to treat several musculoskeletal conditions, being considered safe and effective in the elimination of muscle pain caused by trigger point.

Conclusion The surgeon-dentist can successfully control the majority of TMD patients through their education and self-care, followed by simple reversible treatments without the need for excess drugs. References 1. Velly AM, Schiffman EL, Rindal DB, Cunha-Cruz J, Gilbert GH, Lehmann M, et al. Feasibility of a Clinical Trial of Pain-related Temporomandibular Muscle and Joint

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Disorders: A Survey from the CONDOR Dental. J Am Dent Assoc. 2013; 144(1), e01–e10. Avaliable from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539212/ 2. Martel MO, Finan PH, Dolman AJ, Subramanian S, Edwards RR, Wasan AD, et al. Self-reports of medication side effects and pain-related activity interference in patients with chronic pain: A longitudinal cohort study. Pain. 2015; 156(6), 1092–1100. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/25782367 3. Boudreau D, Von Korff M, Rutter CM, Saunders K, Ray GT, Sullivan MD, et al. Trends in long-term opioid therapy for chronic non- cancer pain. Pharmacoepidemiol Drug Safe. 2009; 18(12), 1166-75. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/19718704 4. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain. 2004; 109(3), 514-9.. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/15157714 5. Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Abuse. 2006; 81(2), 103-7. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/16023304 6. Gudin JÁ, Mogali S, Jones JD, Comer SD. Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use. Postgrad Med. 2013; 125(4), 115–30. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/23933900 7. Wörz R. Drug dependence and withdrawal in chronic pain patients. Fortschr Med. 1994; 10;112(16), 229-31. Avaliable from: https://europepmc.org/abstract/med/8070745 8. Furlan RMMM, Giovanardi RS, Brito ATBO, Brito DBO. The use of superficial heat for treatment of temporomandibular disorders: an integrative review. CoDAS. 2015; 27(2), 207-12. Avaliable from: https://www.ncbi.nlm.nih.gov/pubmed/26107088 9. Unverzagt C, Berglund K, Thomas JJ. Dry needling for myofascial trigger point pain: a clinical commentary. International journal of sports physical therapy. 2015; 10(3), 402-18. Avaliable from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458928/