Long-term hospital care needs after Bothrops atrox envenomation with hemorrhagic stroke in the Brazilian Amazon: 'From social to physical death' - A case report.

Hemorrhagic stroke is a severe complication reported in cases of Bothrops atrox snakebite envenomation. We report an unusual case of a patient who evolved with an intracranial hemorrhagic stroke and was in a coma for more than five years in a tertiary hospital located in Manaus, Amazonas. 52-year-old man, carpenter, resident in the rural area of the municipality of Tabatinga, located 1106 km from Manaus, capital of Amazonas, Brazil, victim of an accident involving Bothrops atrox evolution with cardiorespiratory arrest, acute kidney injury and hemorrhagic stroke. After 43 days of hospitalization in the ICU, he was transferred to the ward, without contact with the environment and family, sent for home treatment, however, without acceptance by family members. During a long hospital stay for a period of 6 years, totally dependent on special care, in a flexed position, using a tracheostomy and mechanical ventilation, diagnosed and treated for hospital infections throughout his hospitalization, he died due to bacterial pneumonia. Losses of autonomy can result in an individual being completely disconnected from social life - a "social death before physical death".

Photobiomodulation Therapy to Treat Snakebites Caused by Bothrops atrox: A Randomized Clinical Trial.

Importance: Bothrops venom acts almost immediately at the bite site and causes tissue damage. Objective: To investigate the feasibility and explore the safety and efficacy of low-level laser therapy (LLLT) in reducing the local manifestations of B atrox envenomations. Design, Setting, and Participants: This was a double-blind randomized clinical trial conducted at Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, Brazil. A total of 60 adult participants were included from November 2020 to March 2022, with 30 in each group. Baseline characteristics on admission were similarly distributed between groups. Data analysis was performed from August to December 2022. Intervention: The intervention group received LLLT combined with regular antivenom treatment. The laser used was a gallium arsenide laser with 4 infrared laser emitters and 4 red laser emitters, 4 J/cm2 for 40 seconds at each application point. Main Outcomes and Measures: Feasibility was assessed by eligibility, recruitment, and retention rates; protocol fidelity; and patients' acceptability. The primary efficacy outcome of this study was myolysis estimated by the value of creatine kinase (U/L) on the third day of follow-up. Secondary efficacy outcomes were (1) pain intensity, (2) circumference measurement ratio, (3) extent of edema, (4) difference between the bite site temperature and that of the contralateral limb, (5) need for the use of analgesics, (6) frequency of secondary infections, and (7) necrosis. These outcomes were measured 48 hours after admission. Disability assessment was carried out from 4 to 6 months after patients' discharge. P values for outcomes were adjusted with Bonferroni correction. Results: A total of 60 patients (mean [SD] age, 43.2 [15.3] years; 8 female individuals [13%] and 52 male individuals [87%]) were included. The study was feasible, and patient retention and acceptability were high. Creatine kinase was significantly lower in the LLLT group (mean [SD], 163.7 [160.0] U/L) 48 hours after admission in relation to the comparator (412.4 [441.3] U/L) (P = .03). Mean (SD) pain intensity (2.9 [2.7] vs 5.0 [2.4]; P = .004), circumference measurement ratio (6.6% [6.6%] vs 17.1% [11.6%]; P < .001), and edema extent (25.8 [15.0] vs 40.1 [22.7] cm; P = .002) were significantly lower in the LLLT group in relation to the comparator. No difference was observed between the groups regarding the mean difference between the bite site temperature and the contralateral limb. Secondary infections, necrosis, disability outcomes, and the frequency of need for analgesics were similar in both groups. No adverse event was observed. Conclusions and Relevance: The data from this randomized clinical trial suggest that the use of LLLT was feasible and safe in a hospital setting and effective in reducing muscle damage and the local inflammatory process caused by B atrox envenomations. Trial Registration: Brazilian Registry of Clinical Trials Identifier: RBR-4qw4vf.

Alternative Postoperative Analgesia Technique for Peripheral Vascular Revascularization: A Case Report.

Peripheral arterial disease (PAD) patients often require surgical peripheral vascular revascularization (PVR), in which postoperative pain management can be challenging. This case report details a 43-year-old female patient with PAD who underwent urgent femoral popliteal bypass with an inverted ipsilateral great saphenous vein and left femoral endarterectomy. Due to contraindications for neuraxial anesthesia and the necessity for continuous anticoagulation, the procedure was performed under general anesthesia (GA) and an unconventional technique with intraoperative perineural catheter (PC) placement to guarantee adequate postoperative analgesia. The surgeon inserted the PC in the vicinity of the femoral nerve under direct visualization before surgical closure. Postoperative analgesia was successfully managed, demonstrating the effectiveness of this approach as part of a multimodal analgesia strategy. This case report suggests that such a technique, supervised by an anesthesiologist and supported by a multidisciplinary team, can provide effective postoperative pain control in PAD patients without interrupting perioperative anticoagulation. Formal protocols for similar procedures can arise, incorporating this analgesic option.

Snakebite envenomations and access to treatment in communities of two indigenous areas of the Western Brazilian Amazon: A cross-sectional study.

BACKGROUND: The indigenous populations of Brazil present poor health indicators and a disproportionate prevalence and case-fatality rate of neglected tropical diseases, including snakebite envenomations (SBEs). This study aims to estimate access to medical care for SBEs and analyze the barriers that prevent victims from accessing healthcare in indigenous communities in two health districts located in the Western Brazilian Amazon. METHODOLOGY/PRINCIPAL FINDINGS: This cross-sectional study used semi-structured interviews to collect data from individuals who experienced SBEs in the Upper Rio Solimões and Upper Rio Negro indigenous health districts. Of the 187 participants, 164 (87.7%) reported that they had access to healthcare and received assistance in a hospital in the urban area of the municipalities. Frequency was 95.4% in the Upper Rio Solimões SIHD, and 69.6% in the Upper Rio Negro SIHD (P<0.0001). The study found that the availability of indigenous medicine as the only choice in the village was the main reason for not accessing healthcare (75%), followed by a lack of financial resources and means of transportation (28.1%). Four deaths were reported from SBEs, resulting in a case-fatality rate of 2.1%. CONCLUSIONS/SIGNIFICANCE: In the study areas, there are records of SBE patients who did not receive medical attention. Availability of pre-hospital emergency transport using motorboats, a greater number of hospitals and better navigability of the Solimões River and its tributaries would make access easier for indigenous people living in the region of the Upper Solimões River. The implementation of cross-cultural hospital care needs to be considered in order to reduce the resistance of indigenous populations in relation to seeking treatment for SBEs.

Prospecting Local Treatments Used in Conjunction with Antivenom Administration Following Envenomation Caused by Animals: A Systematic Review.

Envenomation caused by venomous animals may trigger significant local complications such as pain, edema, localized hemorrhage, and tissue necrosis, in addition to complications such as dermonecrosis, myonecrosis, and even amputations. This systematic review aims to evaluate scientific evidence on therapies used to target local effects caused by envenomation. The PubMed, MEDLINE, and LILACS databases were used to perform a literature search on the topic. The review was based on studies that cited procedures performed on local injuries following envenomation with the aim of being an adjuvant therapeutic strategy. The literature regarding local treatments used following envenomation reports the use of several alternative methods and/or therapies. The venomous animals found in the search were snakes (82.05%), insects (2.56%), spiders (2.56%), scorpions (2.56%), and others (jellyfish, centipede, sea urchin-10.26%). In regard to the treatments, the use of tourniquets, corticosteroids, antihistamines, and cryotherapy is questionable, as well as the use of plants and oils. Low-intensity lasers stand out as a possible therapeutic tool for these injuries. Local complications can progress to serious conditions and may result in physical disabilities and sequelae. This study compiled information on adjuvant therapeutic measures and underscores the importance of more robust scientific evidence for recommendations that act on local effects together with the antivenom.

Bradycardia in a pediatric population after sugammadex administration: case series

Abstract Sugammadex is a distinctive neuromuscular reversal drug that acts by encapsulating the neuromuscular relaxant molecule and dislodging it from its site of action. Sugammadex has been approved for pediatric patients over 2 years of age. Although arrhythmias have been reported, there is no report of adverse effects in healthy children, such as severe bradycardia requiring intervention. We report two cases of severe bradycardia immediately after the administration of sugammadex in healthy children. Our aim is to alert to the occurrence of one of the most severe adverse effects of sugammadex, in the healthy pediatric population as well.

Bradycardia in a pediatric population after sugammadex administration: case series.

Sugammadex is a distinctive neuromuscular reversal drug that acts by encapsulating the neuromuscular relaxant molecule and dislodging it from its site of action. Sugammadex has been approved for pediatric patients over 2 years of age. Although arrhythmias have been reported, there is no report of adverse effects in healthy children, such as severe bradycardia requiring intervention. We report two cases of severe bradycardia immediately after the administration of sugammadex in healthy children. Our aim is to alert to the occurrence of one of the most severe adverse effects of sugammadex, in the healthy pediatric population as well.

Prospecting local treatments used in conjunction with antivenom administration following envenomation caused by animals: a systematic review

Envenomation caused by venomous animals may trigger significant local complications such as pain, edema, localized hemorrhage, and tissue necrosis, in addition to complications such as dermonecrosis, myonecrosis, and even amputations. This systematic review aims to evaluate scientific evidence on therapies used to target local effects caused by envenomation. The PubMed, MEDLINE, and LILACS databases were used to perform a literature search on the topic. The review was based on studies that cited procedures performed on local injuries following envenomation with the aim of being an adjuvant therapeutic strategy. The literature regarding local treatments used following envenomation reports the use of several alternative methods and/or therapies. The venomous animals found in the search were snakes (82.05%), insects (2.56%), spiders (2.56%), scorpions (2.56%), and others (jellyfish, centipede, sea urchin—10.26%). In regard to the treatments, the use of tourniquets, corticosteroids, antihistamines, and cryotherapy is questionable, as well as the use of plants and oils. Low-intensity lasers stand out as a possible therapeutic tool for these injuries. Local complications can progress to serious conditions and may result in physical disabilities and sequelae. This study compiled information on adjuvant therapeutic measures and underscores the importance of more robust scientific evidence for recommendations that act on local effects together with the antivenom.

Case Report: Late-Onset Pneumonitis after Apoica pallida (Insecta: Hymenoptera) Sting with Anaphylactic Reaction in the Brazilian Amazon.

Hymenopteran venoms, inoculated during stings by ants, bees, and wasps, are the most frequent cause of an IgE-mediated systemic hypersensitivity reaction in adults, which is a key process in drastic manifestations of anaphylaxis. Respiratory involvement is usually caused by pulmonary edema but is rarely described as including interstitial pneumonitis or acute respiratory distress syndrome. Here, we describe a case of severe allergic reaction after a sting by Apoica pallens with late-onset pulmonary involvement, including signs of vasoplegia (pleural effusion) and interstitial pneumonitis with mild rhabdomyolysis. The presence of late onset of pulmonary involvement after a severe allergic reaction after a sting by A. pallens shows the importance of keeping a patient with severe reactions under medical care for a minimum of 5 days to avoid serious late complications outside the hospital environment.

Validation of a Culturally Relevant Snakebite Envenomation Clinical Practice Guideline in Brazil.

Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.

História em quadrinhos para educação em saúde bucal: construção, validação e análise da eficácia / Comics for oral health education: construction, validation, and analysis of efficacy

As tecnologias ilustradas tem sido um artifício amplamente utilizado para a educação em saúde bucal, sendo as histórias em quadrinhos um formato ainda pouco explorado no que se refere à validação e análise da sua eficácia para com o público-alvo. Este estudo objetivou avaliar a efetividade de uma história em quadrinhos no processo de educação em saúde bucal a crianças entre 06 e 12 anos atendidas na clínica de Odontopediatria de uma policlínica odontológica na Amazônia brasileira. Uma revista em quadrinhos lúdico-educativa foi confeccionada, validada e incorporada em um kit contendo 01 escova dental, 01 fio dental e 01 creme dental. Posteriormente foi aplicado um questionário com os pais (N=50), antes e depois da entrega dos kits, que avaliava os cuidados de higiene bucal da criança e as impressões sobre o impacto dos quadrinhos sobre a higiene bucal de seus filhos. Os resultados foram analisados descritivamente, por meio de frequências absolutas e porcentagens sendo usado o teste de McNemar (p<0,05). Verificou-se o aumento de 55,32% das crianças que passaram a usar o fio dental após implementação metodológica. Constatou-se, ainda, não haver diferença estatística entre a frequência de escovação após a entrega do kit (p=0.873), havendo, entretanto, aumento significativo na frequência do uso do fio dental entre as crianças avaliadas (p=0.0401). Os quadrinhos mostraram-se estatisticamente eficazes no aumento da frequência do uso do fio dental, tendo a HQ uma boa aceitação tanto das crianças como dos pais.

Illustrated media has been a widely used device for oral health education, with comics being a format that is still under explored in terms of validation and analysis of their effectiveness towards the target audience. This study aimed to evaluate the effectiveness of a comic book in the process of oral health education to children between 6 and 12 years of age attended at the pediatric dentistry clinic of a dental polyclinic in the Brazilian Amazon. A playful-educational comic book was made, validated, and incorporated into a kit containing 01 toothbrush, 01 floss, and 01 toothpaste. Subsequently, a questionnaire was applied with the parents (N=50), before and after the delivery of the kits, which evaluated the child's oral hygiene care and the impressions on the impact of the comics on the oral hygiene of their children. The results were analyzed descriptively, through absolute frequencies and percentages using the McNemar test (p<0.05). There was an increase of 55.32% of the children who started flossing after methodological implementation. It was also found that there was no statistical difference between the frequency of brushing after delivery of the kit (p=0.873), but there was a significant increase in the frequency of flossing among the children evaluated (p=0.0401). The comics were statistically effective in increasing the frequency of flossing, with comic books having a good acceptance of both children and parents.

Efficacy of digital radiography for detecting a second mesiobuccal canal adjacent to unfilled or filled canals.

The aim of this study was to assess the diagnostic accuracy of digital periapical radiography for the detection of the second mesiobuccal (MB2) canal when the adjacent canals are unfilled or filled with gutta percha. Forty human maxillary first molars were selected, 20 of which had an MB2 canal. The presence or absence of the MB2 canal was confirmed using microcomputed tomography. Digital periapical radiographs of each tooth were obtained from 3 horizontal angles before and after the adjacent root canals were filled with gutta percha. Three experienced oral radiologists evaluated all images and indicated the presence or absence of the MB2 canal using a confidence scale of 5 points. To assess intraobserver and interobserver agreement, weighted kappa coefficients were calculated. The diagnostic test (sensitivity, specificity, and accuracy) and area under the receiver operating characteristic curve (Az) values were calculated and compared between groups (n = 40): radiographs of the first molars with unfilled adjacent canals and radiographs of the same teeth with filled adjacent canals. For all observers, intraobserver reproducibility ranged from substantial (0.70) to almost perfect (0.86), and interobserver reproducibility ranged from fair (0.39) to substantial (0.67). Similar values of specificity and Az for the detection of the MB2 canal were observed with unfilled and filled adjacent canals. The sensitivity and accuracy were slightly greater when the adjacent root canals were filled with gutta percha. Detection of the MB2 canal on digital periapical radiographs can be challenging even when obtained at varying horizontal angles, and the presence of gutta percha does not influence the detection.

Licochalcone a Exhibits Leishmanicidal Activity in vitro and in Experimental Model of Leishmania (Leishmania) Infantum.

The efficacy of Licochalcone A (LicoA) and its two analogs were reported against Leishmania (Leishmania) amazonensis and Leishmania (Leishmania) infantum in vitro, and in experimental model of L. (L.) infantum in vitro. Initially, LicoA and its analogs were screened against promastigote forms of L. (L.) amazonensis. LicoA was the most active compound, with IC50 values of 20.26 and 3.88 µM at 24 and 48 h, respectively. Against amastigote forms, the IC50 value of LicoA was 36.84 µM at 48 h. In the next step, the effectivity of LicoA was evaluated in vitro against promastigote and amastigote forms of L. (L.) infantum. Results demonstrated that LicoA exhibited leishmanicidal activity in vitro against promastigote forms with IC50 values of 41.10 and 12.47 µM at 24 and 48 h, respectively; against amastigote forms the IC50 value was 29.58 µM at 48 h. Assessment of cytotoxicity demonstrated that LicoA exhibited moderate mammalian cytotoxicity against peritoneal murine macrophages; the CC50 value was 123.21 µM at 48 h and showed about 30% of hemolytic activity at concentration of 400 µM. L. (L.) infantum-infected hamsters and treated with LicoA at 50 mg/kg for eight consecutive days was able to significantly reduce the parasite burden in both liver and spleen in 43.67 and 39.81%, respectively, when compared with negative control group. These findings suggest that chalcone-type flavonoids can be a promising class of natural products to be considered in the search of new, safe, and effective compounds capable to treat canine visceral leishmaniosis (CVL).

Prevalência e complicações das lesões dentárias traumáticas / Prevalence and consequences of traumatic dental injuries

Introdução: os traumatismos dentários precisam ser corretamente diagnosticados e tratados desde o primeiro atendimento, com a finalidade de minimizar as alterações tardias que poderão complicar o tratamento endodôntico. Objetivo: avaliar a prevalência dos traumatismos dentários na dentição permanente e apresentar as principais alterações subsequentes a estes. Metodologia: foi realizado um estudo observacional da prevalência de traumatismo dentário na dentição permanente e da ocorrência de possíveis complicações endodônticas pós-traumáticas, por meio do acompanhamento clínico e radiográfico dos pacientes atendidos na disciplina de Endodontia Clínica da Faculdade de Odontologia da Universidade Federal da Bahia, no período de 2012 a 2016. Resultados: os dados obtidos foram tabulados e a análise dos resultados incluiu distribuição de frequência e teste Qui-quadrado com nível de significância de 5%. A amostra compreendeu 178 dentes de 89 pacientes, sendo a sua maioria do gênero masculino (54%). A faixa etária mais prevalente foi dos 11 aos 20 anos de idade. A maxila foi a região mais afetada, sendo os dentes anteriores os mais acometidos (83%). A queda foi o fator etiológico predominante (61%) e a fratura coronária não complicada foi o tipo de trauma mais prevalente (23,2%), seguido da luxação lateral (19,7%) e da avulsão (17,7%). A necrose da polpa foi a complicação endodôntica mais frequente (42,7%), seguida da reabsorção radicular externa com 18,3%. Conclusão: pôde-se observar uma alta ocorrência das complicações pós-traumáticas, sendo necessário o tratamento e o acompanhamento criterioso desses pacientes com o intuito de evitar a perda dentária.

Introduction: dental trauma needs to be correctly diagnosed and treated from the first visit, in order to minimize late changes that may complicate endodontic treatment. Objective: To evaluate the prevalence of dental trauma in permanent dentition and to present the main subsequent changes. Metodology: an observational study of the prevalence of dental trauma in permanent dentition and the occurrence of possible post-traumatic endodontic complications was carried out through clinical and radiographic follow-up of patients treated at the Clinical Endodontics discipline of the Federal University School of Dentistry. Bahia, from 2012 to 2016. Results: the data obtained were tabulated and the analysis of the results included frequency distribution and Chi-square test with a significance level of 5%. The sample comprised 178 teeth from 89 patients, most of them male (54%). The most prevalent age group was from 11 to 20 years old. The maxilla was the most affected region, with the anterior teeth being the most affected (83%). Fall was the predominant etiological factor (61%) and uncomplicated coronary fracture was the most prevalent type of trauma (23.2%), followed by lateral dislocation (19.7%) and avulsion (17.7%). . Pulp necrosis was the most common endodontic complication (42.7%), followed by external root resorption with 18.3%. Conclusion: it was observed a high occurrence of post-traumatic complications, requiring the treatment and careful monitoring of these patients in order to prevent tooth loss.

General anesthesia combined with erector spinae plane block for ductus arteriosus closure: two case reports / Anestesia geral associada a bloqueio do plano do músculo eretor da espinha para encerramento de persistência de canal arterial: dois relatos de caso

Abstract Background: Failure of ductus arteriosus closure in preterm neonates results in a left-to-right shunt that leads to variable severities of hemodynamic and respiratory distress. When medical therapy fails, surgical ligation via left lateral thoracotomy remains an alternative approach and can be performed in the operating room or at the bedside with a low mortality rate. Opioid-based anesthesia is a frequent choice among anesthesiologists who manage patent ductus arteriosus cases based on the suppression of the stress response and maintenance of hemodynamic stability. This rationale suggests that regional anesthesia may also be an advantageous technique and may benefit earlier weaning from ventilation. Blocking afferent signals before incision may also modulate the long-term consequences of altered sensory perception and pain responses. Case report: We present two cases of general anesthesia combined with erector spinae plane block as part of multimodal anesthesia in premature twins undergoing patent ductus arteriosus closure. Discussion: In these cases, the use of erector spine plane block combined with general anesthesia was efficient to minimize the negative impact of surgery and allowed a reduction in the amount of intraoperative opioid use for patent ductus arteriosus closure.

Resumo Justificativa: A persistência do canal arterial em neonatos prematuros resulta em shunt esquerdo-direito com alterações hemodinâmicas e desconforto respiratório de gravidade variável. Quando o tratamento clínico não é bem sucedido, o fechamento cirúrgico via toracotomia lateral esquerda continua sendo a abordagem alternativa, e pode ser realizado no centro cirúrgico ou à beira leito com baixa taxa de mortalidade. A anestesia baseada em opioides é frequentemente escolhida pelos anestesiologistas nos casos de fechamento de canal arterial devido à supressão de resposta ao estresse e manutenção da estabilidade hemodinâmica. Essa justificativa sugere que a anestesia regional também pode ser uma técnica vantajosa e que promove desmame mais precoce do ventilador. O bloqueio dos estímulos aferentes antes da incisão também pode modular os efeitos no longo-prazo, tanto da percepção sensorial quanto das respostas à dor. Relato de caso: Apresentamos dois casos de anestesia geral associada a bloqueio do plano do músculo eretor da espinha como parte de anestesia multimodal em gêmeos prematuros submetidos a fechamento de canal arterial persistente. Discussão: Nos dois casos descritos, o bloqueio do plano do músculo eretor da espinha associado à anestesia geral foi eficiente para minimizar o impacto negativo da cirurgia, e possibilitou a redução na quantidade de opioide usado durante cirurgia para fechamento de persistência canal arterial.

[General anesthesia combined with erector spinae plane block for ductus arteriosus closure: two case reports]. / Anestesia geral associada a bloqueio do plano do músculo eretor da espinha para encerramento de persistência de canal arterial: dois relatos de caso.

BACKGROUND: Failure of ductus arteriosus closure in preterm neonates results in a left-to-right shunt that leads to variable severities of hemodynamic and respiratory distress. When medical therapy fails, surgical ligation via left lateral thoracotomy remains an alternative approach and can be performed in the operating room or at the bedside with a low mortality rate. Opioid-based anesthesia is a frequent choice among anesthesiologists who manage patent ductus arteriosus cases based on the suppression of the stress response and maintenance of hemodynamic stability. This rationale suggests that regional anesthesia may also be an advantageous technique and may benefit earlier weaning from ventilation. Blocking afferent signals before incision may also modulate the long-term consequences of altered sensory perception and pain responses. CASE REPORT: We present two cases of general anesthesia combined with erector spinae plane block as part of multimodal anesthesia in premature twins undergoing patent ductus arteriosus closure. DISCUSSION: In these cases, the use of erector spinae plane block combined with general anesthesia was efficient to minimize the negative impact of surgery and allowed a reduction in the amount of intraoperative opioid use for patent ductus arteriosus closure.

Tratamento alternativo para dentes traumatizados com reabsorção radicular inflamatória: 4 anos de acompanhamento / Alternative treatment for traumatized teeth with inflammatory root resorption: 4 years follow-up / Tratamiento alternativo para dientes traumatizados con reabsorción radicular inflamatoria: 4 años de seguimiento

Objetivo: Este relato descreve o tratamento de um incisivo central superior previamente traumatizado, afetado pela reabsorção radicular inflamatória interna / externa. Método: Trata-se do relato de caso de um paciente com 12 anos de idade que relatou um trauma de queda um ano antes da consulta, causando fratura da coroa e luxação intrusiva no incisivo central superior direito. Os exames clínicos verificaram sensibilidade à percussão e descoloração da coroa. Radiograficamente, as áreas radiolúcidas sugeriram reabsorção radicular inflamatória (no terço da raiz cervical) e lesão periapical. Resultados: O tratamento endodôntico foi realizado, com uma pasta de hidróxido de cálcio com paramonoclorofenol canforado inserida no canal radicular por 2 meses. Quando uma barreira calcificada na área apical foi observada radiograficamente, toda a raiz foi obturada com agregado de trióxido mineral (MTA). O dente foi acompanhado por 4 anos, mostrando regressão dos sintomas, cicatrização por reabsorção e também aumento no comprimento radicular. Conclusão: O presente caso mostrou que o tratamento endodôntico associado ao MTA promoveu a remodelação óssea da área periapical e paralisou a reabsorção.

Objective: This report describes the treatment of a previously traumatized central central incisor affected by internal/external inflammatory root resorption. Method: This is the case report of a 12-year-old patient who reported a fall trauma one year before the consultation, causing crown fracture and intrusive dislocation in the right upper central incisor. Clinical examinations verified sensitivity to percussion and discoloration of the crown. Radiographically, radiolucent areas suggested inflammatory root resorption (in the third of the cervical root) and periapical lesion. Results: Endodontic treatment was performed with a calcium hydroxide paste with canouted paramonochlorophenol inserted into the root canal for 2 months. When a calcified barrier in the apical area was observed radiographically, the entire root was computed with mineral trioxide aggregate (MTA). The tooth was followed for 4 years, showing regression of symptoms, healing by resorption and also increase in root length. Conclusion: The present case showed that endodontic treatment associated with MTA promoted bone remodeling of the periapical area and paralyzed resorption.

Objetivo: Este informe describe el tratamiento de un incisivo central central previamente traumatizado afectado por la resorción de raíz inflamatoria interna/externa. Método: Este es el informe del caso de un paciente de 12 años que reportó un trauma de caída un año antes de la consulta, causando fractura de corona y dislocación intrusiva en el incisivo central superior derecho. Los exámenes clínicos verificaron la sensibilidad a la percusión y la decoloración de la corona. Radiográficamente, las áreas radiolúcidas sugirieron resorción inflamatoria de la raíz (en la tercera de la raíz cervical) y lesión periapical. Resultados: El tratamiento endodóntico se realizó con una pasta de hidróxido de calcio con paramonoclorofenol canouted insertado en el conducto radicular durante 2 meses. Cuando se observó radiográficamente una barrera calcificada en el área apical, toda la raíz se calculó con el agregado de trióxido mineral (MTA). El diente fue seguido durante 4 años, mostrando regresión de los síntomas, curación por resorción y también aumento en la longitud de la raíz. Conclusión: El presente caso mostró que el tratamiento endodóntico asociado con la MTA promovía la remodelación ósea de la zona periapical y la resorción paralizada.

Abordagem Terapêutica de Fratura Radicular com 30 meses de Acompanhamento: Relato de Caso Clínico / Therapeutic Approach Root Fracture with 30 Months Follow: Clinical Case Report

Introdução: os traumatismos dentários são muito frequentes e estão entre os principais problemas de saúde pública. As fraturas radiculares tem uma ocorrência que varia entre 0,5 a 7% e acometem principalmente os incisivos superiores de crianças e adultos jovens. Portanto, necessitam de um diagnóstico preciso para que seja realizado um plano de tratamento e acompanhamento adequado. Objetivo: O presente estudo tem como objetivo relatar o caso clínico de fratura radicular em terço médio de um dente anterior, que foi tratado de forma conservadora e acompanhado por 30 meses. Relato de caso: O paciente gênero masculino, 42 anos, que procurou atendimento odontológico 23 dias após ter sofrido uma agressão física acometendo a face e o incisivo central superior. Ao exame clínico, observou-se uma discreta extrusão do 21 e ao exame radiográfico periapical detectou-se uma fratura horizontal no terço médio da raiz do mesmo dente. Foi realizada uma contenção semirrígida e desgaste incisal do 21. Após 45 dias, a contenção foi removida e o paciente orientado a retornar periodicamente para controle clínico e radiográfico. Após 30 meses de proservação, verifica-se ausência de dor e de mobilidade, resposta positiva aos testes térmicos de sensibilidade pulpar e cicatrização da linha de fratura ao exame radiográfico e tomográfico. Conclusões: Após este período de acompanhamento, pode-se concluir que o tratamento conservador proposto foi efetivo na manutenção do dente traumatizado, uma vez que este apresenta-se vital e desempenhando suas funções fisiológicas e estéticas

Introduction: dental injuries are very frequent and are among the main problems of public health. The root fractures occur between 0,5 a 7% and mainly affect the central incisors of children and young adults. So, its necessary a certain diagnosis and a proper treatment and follow-up plan. Objective: this study aims to report the clinical case of root fracture in the middle third of a previous tooth, which was treated conservatively and followed up for 30 months. Case report: the male patient, 42 years old, who sought dental care 23 days after having suffered a physical aggression involving the face and upper central incisor. Clinical examination revealed a discrete extrusion of the 21 and periapical radiographic examination a horizontal fracture was detected in the middle third of the root of the same tooth. A semi-rigid restraint and incisal wear of the 21 were performed. After 45 days, a restraint was removed and the patient was instructed to return periodically for clinical and radiographic control. During a period of 30 months of proservation, there is no pain and mobility, positive response to the thermal pulpal sensitivity tests and healing of the fracture line in the radiographic and tomography examination. Conclusions: After this follow up, it was concluded that the conservative treatment proposed was effective in the maintenance of the traumatized tooth, since it is vital and performs its physiological and aesthetic functions.

Efeitos do laser de diodo de alta potência e da fotobiomodulação em dentes de ratos reimplantados tardiamente / Effects of high power diode laser and photobiomodulation therapy prior delayed replantation in rats

Resumo Introdução A busca por protocolos efetivos para reduzir a incidência de reabsorções radiculares e favorecer a reparação do ligamento periodontal perdido ainda representa um grande desafio, tendo em vista o prognóstico desfavorável dos reimplantes dentais tardios. Objetivo Avaliar, por meio da análise histológica, os efeitos do laser de alta potência e da fotobiomodulação na ocorrência de reabsorção radicular e no reparo periodontal, em dentes reimplantados tardiamente. Material e método Foram utilizados 50 incisivos centrais direitos de ratos Wistar. Após a extração, os espécimes foram divididos em cinco grupos (n = 10): G1 (controle positivo): reimplante imediato; G2 (controle negativo): reimplante tardio (RT): espécimes mantidos em ambiente seco por 60 minutos, sem tratamento adicional; G3: RT associado ao tratamento da superfície radicular com laser diodo de alta potência (810 nm, 1.5 W); G4: RT + superfícies radiculares e feridas alveolares tratadas com fotobiomodulação (laser diodo 660 nm, 30 mW e 780 nm, 40 mW, respectivamente); G5: RT + superfícies radiculares irradiadas com laser de alta e alvéolos com fotobiomodulação, nos mesmos parâmetros que G3 e G4, respectivamente. Após 60 dias, os animais foram eutanasiados. Os espécimes foram processados para análise histológica. Resultado G3 e G5 apresentaram as menores médias de scores com relação à ocorrência de reabsorções radiculares e anquilose, quando comparados a G2 e G4 (Teste Kruskall-Wallis, p<0,05). Com relação ao reparo periodontal, todos os grupos experimentais (G3, G4 e G5) apresentaram médias de escores inferiores (Teste Kruskall-Wallis, p<0,05) comparadas ao G1 e semelhantes ao G2 (Teste Kruskall-Wallis, p>0,05). Conclusão O laser de alta potência, associado ou não à fotobiomodulação, diminuiu a ocorrência das reabsorções radiculares e da anquilose, e a fotobiomodulação não favoreceu o controle das reabsorções radiculares nem o reparo periodontal.

Abstract Introduction The search for effective protocols for a lower incidence of root resorptions reduction and for a favor periodontal repair still represents a great challenge, considering the unfavorable prognostic of the delayed replanted tooth. Objective To evaluate by histologic analyses the effects of high power diode laser and photobiomodulation on the occurrence of root resorption and on the tissue repair of delayed replanted teeth. Material and method Fifty right central incisors of Wistar rats were used. After the extraction, the specimens were assigned to 5 groups (n=10): G1 and G2 were the control groups-with no treatment and they were respectively submitted to immediate and delayed replantation (DR- 60 minutes after the extraction). The other three groups received tissue repair treatment prior the DR: G3 - root surfaces were irradiated with high power laser (810 nm, 1.5 W); G4- root surfaces and the alveolar wounds were irradiated with low power laser (photobiomodulation), respectively with 660 nm, 90 mW and 780 nm, 40 mW; G5- root surfaces were irradiated with high power and the alveolar wound received photobiomodulation with the same parameters used in G3 and G4. After 60 days the animals were euthanized. The specimens were processed for histological analyses. Result The histologic analysis showed lower means values of scores of root reabsorptions and ankylosis in G3 and G5 when compared to G2 and G4 (Kruskall-Wallis test, p>0.05). Regarding the periodontal repair, all the experimental groups (G3, G4 and G5) presented lower means values of scores than G1 (Kruskall-Wallis test, p <0.05) and similar values to G2 (Kruskall-Wallis test, p>0.0.5). Conclusion High power laser reduced the occurrence of root resorption and photobiomodulation did not enhance the tissue healing process in delayed tooth replantation in rats.

Anatomia radicular dos primeiros pré-molares inferiores em uma população do nordeste do Brasil / Root anatomy of the mandibular first premolars in a population of northeast Brazil

Objetivo: Avaliar a anatomia radicular de primeiros pré- -molares inferiores em uma população do Nordeste do Brasil, por meio da análise externa das raízes, radiografia digital e diafanização. Materiais e Método: Cem dentes extraídos foram selecionados. A análise clínica avaliou as características radiculares e incluiu o número de raízes, a presença e o tipo de sulcos radiculares nas superfícies proximais, ocorrência e tipo de dilaceração da raiz, tamanho e forma da raiz. Dois exames radiográficos (ortogonal e mesio-distal) foram realizados, e em seguida a diafanização. Resultados: Os resultados revelaram maior ocorrência de raiz única (96%), com formato piramidal cônica (53%), presença de sulcos radiculares (71%) e dilaceração apical (46%). Na posição ortogonal, 75% dos dentes apresentaram um canal, enquanto no mesio-distal esse valor foi de 57% (p = 0,00). Na diafanização, a ramificação mais comum foi a intercanal (38,9%) e, para o tipo Vertucci, o tipo I foi o mais frequente (63%). Ao comparar a classificação de Vertucci na radiografia e na diafanização, houve diferença estatisticamente significante (p = 0,00). Conclusões: Os primeiros pré-molares inferiores, na população estudada, apresentaram grande variação da anatomia radicular, o que pode gerar dificuldades durante o tratamento endodôntico.

Objetive: To evaluate the root anatomy of the mandibular first premolars in a population of the Northeast of Brazil, through the external root analysis, digital radiography and diaphanization. Material and Method: One hundred extracted mandibular first premolar were selected. The analysis included the number of roots, the presence and type of radicular grooves at the proximal surfaces, the presence and type of root dilaceration, the root size and shape. Two radiographic examinations (orthogonal and mesio-distal) were performed, followed by diaphanization of the teeth. Results: The results revealed a higher prevalence of single rooted teeth (96%), with conical pyramidal aspect (53%), radicular grooves (71%) and apical dilaceration (46%). At the orthogonal position, 75% of the teeth presented one canal, whereas in the mesio-distal this value was 57% (p=0.00). In the diaphanization, the most common branch was the intercanal (38.9%) and regarding the Vertucci's classification, type I was the most frequent (63%). When comparing the Vertucci's classification in the radiography and in the diaphanization, there was a statistically significant difference (p = 0.00). Conclusions: The mandibular first premolars, in the study population, presented a great variation of the root anatomy, which may generate difficulties during endodontic treatment.