Procedimentos de imagem em Odontologia no Sistema Único de Saúde e a expansão da atenção secundária: série entre 2000-2016 / Dental imaging procedures in the Unified Health System and the expansion of secondary care: series between 2000-2016

Resumo O objetivo foi analisar a série temporal de procedimentos de imagem em Odontologia realizados entre os anos de 2000 e 2016 no Sistema Único de Saúde (SUS). Os dados foram obtidos do Sistema de Informações Ambulatoriais (SIA-SUS). Foram analisadas a influência da Política Nacional de Saúde Bucal de 2004, da Portaria nº 600/2006 (institui o financiamento dos Centros de Especialidades Odontológicas - CEOs) e Portaria nº 1.234/2013 (Incentivo financeiro do Programa de Melhoria do Acesso e da Qualidade - PMAQ-CEO). Apresentou-se análises descritivas dos anos inicial e final da série temporal, avaliando tendências e sazonalidade em sete tipos de procedimentos. A série temporal das taxas de exames radiográficos periapicais/interproximais demonstrou tendência de aumento moderado e foi a única em que se observou o impacto da política de implementação financeira dos CEOs, mas não do PMAQ-CEO. Os exames extraorais como: radiografia panorâmica, Tomografia Computadorizada (TC) da face/Articulação Temporomandibular (ATM) e Ressonância Magnética (RM) da ATM possuem forte tendência de aumento apesar das taxas serem muito baixas. Conclui-se que entre os anos 2000 e 2016, a política de expansão da atenção secundária, aumentou o uso de exames de imagem periapical/interproximal.

Abstract The scope of this paper was to analyze the time series of dental procedures performed between 2000 and 2016 in the Brazilian Unified Health System (SUS). The data were obtained from the Outpatient Information System of the SUS (SIA-SUS). The influence of the 2004 National Oral Health Policy of Ordinance No. 600/2006 (which instituted the financing of Dental Specialty Centers - CEOs), and Ordinance No. 1,234/2013 (Financial incentive for the Program for Enhancement of Quality and Access - PMAQ-CEO) were analyzed. Descriptive analyses of the initial and final years of the time series were presented, assessing trends and seasonality in seven types of imaging procedures. The time series of rates of periapical/bitewing radiographic exams revealed a trend of moderate increase and was the only area in which the impact of the financial implementation policy of the CEOs was observed, though not of the PMAQ-CEO. Extraoral imaging exams, such as panoramic radiography, facial CT/TMJ and TMJ MRI revealed a strong upward trend, despite the very low rates. The conclusion reached is that between 2000 and 2016, the policy of expansion of secondary care increased the use of periapical/bitewing imaging exams.

Low Body Mass Index as a Risk Factor for the Onset of Porosity of the Mandibular Bone in the Elderly

ABSTRACT Objective: To investigate whether a low body mass index (BMI) has a significant relationship with mandibular bone porosity progression by conducting a mandibular inferior cortex (MIC) classification in elderly Japanese people. Material and Methods: A total of 266 study subjects, aged 70 at baseline, were recruited for this study, conducted from 1998 to 2007. The subjects were divided into two groups according to changes in the MIC on serial panoramic radiographs during this nine-year study period: a no change group (MIC-NC) and a change group (MIC-C). All subjects in the MIC-C showed changes trending toward greater fragility. We evaluated the BMI at baseline. Logistic regression analysis was performed to assess the relationship between the MIC condition during the nine-year period (0: MIC-NC, 1: MIC-C) and BMI (kg/m2) adjusted for gender, current health status (CHS), and smoking habit (SH) at baseline. Results: The mean and standard deviations of the BMI at baseline in the MIC-NC and MIC-C were 22.8 ± 2.1 and 21.8 ± 2.5 kg/m2 for males and 23.1 ± 2.9 and 21.9 ± 2.4 kg/m2 for females. There was a significant relationship between the MIC condition and the BMI in both males (p=0.04) and females (p=0.01). The logistic regression analysis revealed a significant association between the MIC condition over the nine-year period and the BMI (OR=0.84, p=0.003), which was adjusted depending on the gender (OR=5.18, p=0.000), CHS (OR=0.53, p=0.015), and SH (OR=4.15, p=0.002) at baseline. Conclusion: A low BMI carries a risk of developing mandibular bone porosity by measuring the MIC condition in panoramic radiographs.

Prevalencia de lesiones ateroscleróticas carotídeas en radiografía panorámica y su relación con factores de riesgo cardiovascular en brasileños / Prevalence of atherosclerotic carotid lesions on panoramic radiography and relationship with cardiovascular risk factors in Brazilians

RESUMEN: Aunque la radiografía panorámica no es una prueba de diagnóstico inicial para detectar la aterosclerosis carotídea, no podemos ignorar su valor al ver estas lesiones como hallazgos incidentales que pueden ser grandes aliados en el diagnóstico temprano y la prevención de eventos vasculares graves. El objetivo de este estudio fue evaluar la prevalencia de calcificaciones en la bifurcación de la arteria carótida en las radiografías panorámicas de rutina como principio diagnóstico, así como su relación con los factores de riesgo cardiovascular en individuos brasileños. Se analizaron 449 exámenes de radiografía panorámica de la base de datos del Departamento de Radiología de la Facultad de Odontología de Piracicaba, UNICAMP, São Paulo, Brasil. Después de obtener mediciones de la presión arterial e información sobre el tabaquismo y las enfermedades sistémicas, fue buscado en la radiografía panorámica la presencia o ausencia de la masa radiopaca en las regiones de las vértebras cervicales C3-C4. En el caso de una imagen sugestiva de ateroma, se realizó una radiografía anteroposterior para confirmar el diagnóstico. Aplicamos la prueba estadística de Chi-cuadrado con distribución normal y muestras independientes y aleatorias con un intervalo de confianza del 95 %. La confirmación de calcificaciones carotideas se produjo en el 8,5 % de la población de estudio (38 casos). No encontramos ninguna relación entre la presencia de calcificaciones con el tabaquismo, con el sexo o con datos previos de antecedentes familiares. Sin embargo 49,1 % de los casos estaban por encima de sesenta años y tenía asociación significativa con la hipertensión (P = 0,006). El mayor riesgo se presenta en pacientes ancianos hipertensos y, por lo tanto, hacemos hincapié en la importancia de una observación minuciosa de las radiografías panorámicas en la búsqueda de cualquier alteración de la anatomía normal y si es así, proceder con la derivación lo antes posible para un diagnóstico concluyente por parte de un especialista, pudiendo así ayudar en la prevención de episodios vasculares graves.

SUMMARY: Although panoramic radiography is not an initial diagnostic test for detecting carotid atherosclerosis, we cannot ignore its value in viewing these lesions as incidental findings that can be great allies in early diagnosis and prevention of serious vascular events. The aim was to evaluate the prevalence of calcifications in the bifurcation of the carotid artery on routine panoramic radiographs as a diagnostic principle, as well as its relationship with cardiovascular risk factors in Brazilians. We analyzed 449 panoramic radiography exams from the database of the Department of Radiology of the Faculty of Dentistry of Piracicaba, UNICAMP, São Paulo, Brazil. After obtaining blood pressure measurements and information on smoking and systemic diseases, the researcher observed on the panoramic radiograph, the presence or absence of the radiopaque mass in the regions of the cervical vertebrae C3-C4. In the case of a suggestive image of atheroma, an anteroposterior radiography was performed to confirm the diagnosis. The Chi-square test of normal distribution for independent and random samples with a 95 % confidence interval was applied to the data. Confirmation of carotid calcifications occurred in 8.5 % of the study population (38 cases). We did not find any relationship between the presence of calcifications with smoking, sex or previous family history. However, 49.1 % of cases occurred above sixty years old and there was a significant relationship with hypertension (P = 0.006). The greatest risk was presented in elderly and hypertensive patients, so we highlight the importance of a thorough observation by the dentist of panoramic radiographs to detect any alteration of the normal anatomy and in the positive case, proceed with the referral as soon as possible for a conclusive diagnosis by a specialist, being able to thus assist in the prevention of severe vascular episodes.

Granuloma Periférico de Células Gigantes e Hiperparatiroidismo. Presentación de un Caso / Peripheral Giant Cell Granuloma and Hyperparathyroidism. Case Report

RESUMEN: Se presenta el caso de un paciente sexo femenino 31 años, insuficienciente renal crónica en hemodiálisis, hipertensa secundaria, consulta por aumento de volumen oral en relación a encía marginal vestibular izquierda, 6 meses de evolución. Al examen se observa aumento de volumen de 15 mm en relación a piezas. 3.6 y 3.7. Radiografía muestra compromiso periodontal pieza 3.7. Se realiza biopsia excisional y exodoncia pieza 3.7. Histopatología informa granuloma periférico de células gigantes. Se solicitan exámenes de laboratorio para estudio de hiperparatiroidismo (PTH elevada, calcemia fosfatemia normales). Evoluciona favorablemente. Sin signos de recidiva a los 3 meses. El diagnóstico histopatológico de lesión de células gigantes debe ser complementado con la clínica, exámenes de laboratorio e imagenología, el objetivo final es definir si tal diagnóstico corresponde a un tumor pardo, a un granuloma central de células gigantes o a un granuloma periférico de células gigantes. En la literatura los reportes de asociación entre granuloma periférico de células gigantes e hiperparatiroidismo son escasos. Este caso corresponde a granuloma periférico células gigantes, asociado a hipersecreción de paratohormona.

ABSTRACT: A 31-year-old female patient with chronic renal insufficiency in hemodialysis and secondary hypertension consulted due to an enlarging intraoral lesion in relation to the left marginal vestibular gingival, with 6 months of evolution. A 15mm mass in relation to mandibular left molars was noted. Radiograph showed periodontal involvement of mandibular left second molar. Excisional biopsy and tooth 3.7 extraction were performed. Histopathology reported a peripheral giant cell granuloma. Laboratory tests were requested for suspected hyperparathyroidism (aiding in the diagnosis) (high PTH, normal phosphatemia and calcemia). Evolution was favorable, without signs of reappearance after 3 months. The histopathological diagnosis of giant cell lesions should be complemented with clinical, laboratory and imaging tests. The final objective is to make the differential diagnosis between brown tumor, central giant cell granuloma and peripheral giant cell granuloma because the treatment varies considerably. There are few reports in the literature about the association between peripheral giant cell granuloma and hyperparathyroidism. This case corresponds to peripheral giant cell granuloma, possibly associated with parathormone hypersecretion.

Conservative Treatment of Chronic Osteomyelitis Associated with Florid Osseous Dysplasia / Tratamiento Conservador de la Osteomielitis Crónica Asociada con Displasia Ósea Florida

ABSTRACT: Florid osseous dysplasia (FOD) is an extensive form of osseous dysplasia where normal trabecular bone is substituted by fibrous connective tissue and amorphous mineralized tissue. Usually, the lesions are mainly asymptomatic and the patients should be followed with clinical and imaging examination, requiring no intervention. Nevertheless, due to the poor vascularization of the lesion and to local trauma, secondary infections and osteomyelitis may occur. Patients may present with pain, mucosal ulceration, lesion exposure in the oral cavity, fistula and swelling. In such cases, the correct diagnosis and management of the lesion is decisive to reestablish patient's health and quality of life. The aim of this article is to present a case of complicating secondary chronic osteomyelitis treated successfully with conservative intervention. A 68-year-old black female patient reported a "swelling of the gums" that was present for eleven years, with episodes of periodic pain and swelling. On physical examination, a papule with suppuration in the alveolar mucosa in the right side of the mandible was observed. Panoramic radiography and CBCT showed a mixed lesion surrounded by sclerotic bone. The patient was diagnosed with chronic osteomyelitis in association with FOD and treated with antibiotic therapy together with surgical curettage. The incidence, etiophatology, differential diagnosis, treatment and prevention of secondary osteomyelitis associated with FOD are discussed in the light of literature. This information might assist the dentists while choosing the best treatment options for similar cases.

RESUMEN: La displasia ósea florida (DOF) es una forma de displasia ósea donde el hueso trabecular normal es sustituido por tejido conectivo fibroso y tejido mineralizado amorfo. En general, las lesiones son de origen asintomático y los pacientes deben ser seguidos con el examen clínico. Sin embargo, debido a la pobre vascularización de la lesión y al trauma local, pueden producirse lesiones secundarias y osteomielitis. Los pacientes pueden presentarse con dolor, ulceración mucosa, lesión de exposición en la cavidad oral, fístula y edema. En estos casos, el correcto diagnóstico y tratamiento de la lesión es decisivo para reestabilizar la salud y la calidad de la vida. El objetivo de este artículo consistió en presentar un caso de complicación secundaria crónica de osteomielitis tratados con tratamiento conservador. El paciente, negro, de 68 años de edad, consulta por "hinchazón de las encías" que se presentó durante once años, con episodios de dolor. En el examen intraoral, se observó una pápula con supuración en la mucosa alveolar en el lado derecho de la mandíbula. La radiografía panorámica y CBCT mostraron una lesión mixta rodeada de hueso esclerótico. El paciente fue diagnosticado con osteomielitis crónica en asociación con DOF y fue tratado con tratamiento antibiótico junto con curetaje quirúrgico. La incidencia, la etiopatología, el diagnóstico diferencial, el tratamiento y la prevención de la osteomielitis secundaria asociada con DOF se discuten a la luz de la literatura. Esta información puede ayudar a los dentistas a elegir las mejores opciones de tratamiento para casos similares.

Consideraciones clínicas e imagenológicas de la osteoartrosis en la articulación temporomandibular / Clinical and imaging remarks on temporomandibular joint osteoarthrosis

La osteoartrosis es una enfermedad degenerativa que, instalada en la articulación temporomandibular, genera efectos deletéreos en los tejidos blandos y óseos que la constituyen. En los tejidos duros se destaca la aparición de procesos osteolíticos a nivel condilar y de la cavidad glenoidea con cambios morfológicos importantes. Estas modificaciones están íntimamente relacionadas con el debilitamiento y/o destrucción de los tejidos blandos que ocurren previamente. Los síntomas que se presentan con mayor frecuencia en esta afección son la alteración del rango de movimiento, el dolor y, el más característico, la crepitación durante el examen con estetoscopio. La frecuencia de aparición alcanza entre un 8% y un 18%. Las causas para su documentación son variables y están vinculadas al desplazamiento discal, el trauma, hormonales y la inestabilidad oclusal, siendo el aumento de carga (bruxismo) la de mayor significación. El examen imagenológico puede documentar aplanamiento de los componentes óseos, disminución del espacio articular, discontinuidad de las corticales, esclerosis subcondral, osteofitos, quistes subcondrales y cuerpos libres periarticulares. En ocasiones la radiografía panorámica puede ser poco demostrativa para la documentación de esas particularidades; por el contrario, la tomografía computada es un excelente procedimiento diagnóstico. El aporte de la IRM es relevante en la ubicación del disco articular; asimismo, posibilita la observación de colección de fluido en los espacios articulares, generando una señal hiperintensa. Tratamiento: actuar principalmente para disminuir la carga sobre la ATM y,`por lo tanto, concientizar al paciente de la presencia del bruxismo, instalar un dispositivo oclusal miorrelajante (DOM) y suplementar con analgésicos, antiinflamatorios y antiartrósicos. Cuando la OA está asociada al desplazamiento discal, debe indicarse un dispositivo oclusal de desplazamiento anterior mandibular (DODAM) (AU)

Osteoarthrosis is a degenerative disease. When is located in the TMJ produces deleterious effects in its soft and hard tissues, osteolytic processes on condyle and glenoid cavity in the latter, with significant morphological changes, closely related to weakening and destruction of the tissues that had happened previously. Symptoms most frequent are alteration of the range of movement, pain and,the most characterystic, cracking while examination through stethoscope. Its frequency is between 8 and 18%.Causes for its documentation are variable and related to disc displacement, trauma, hormones and occlusal unsteadiness, being de increase of charge (clenching) the most relevant. Imaging can show flattening on osseusparts,, the articular space, discontinuation of cortexes, subchondral sclerosis, osteophytes, subchondral cysts,and loose particular bodies. Sometimes orthopantomograph may be barely demonstrative to document these phenomena, conversely CT is an excellent diagnostic procedure. The contribution of MRI is relevant to locate articular disc, and facilitate visualize fluid collection within the articular spaces, producing a hiperintense signal. Treatment: to act mainly for diminishing charge on the TMJ, so to raise patients conscience of the presence of clenching, install a myorelaxant occlusal device (DOM) and additionally analgesics, antiinflamatories and antiarthrosis When osteoarthrosis is associated with disc displacement and occlusal device for anterior mandibular displacement (DODAM) is suitable(AU)

Temporomandibular joint disorders as the only manifestation of juvenile idiopathic arthritis: a case report / Comprometimento da articulação temporomandibular como única manifestação da artrite idiopática juvenil: um relato de caso

ABSTRACT Juvenile idiopathic arthritis is a term used to include all chronic childhood arthritis of unknown etiology. It is characterized by chronic inflammation persisting for at least 6 weeks, beginning before 16 years of age. The characteristics present are chronic synovitis, arthralgia, impaired joint mobility in at least one joint, and erosion with destruction of cartilage and subchondral bone, that could be associated or not with systemic involvement, according to each subtype of the disease. During the pathologic process, the temporomandibular joint can be involved by the juvenile idiopathic arthritis, resulting in severe mandibular dysfunction, with higher frequency in female patients. Initially, these lesions can show minor alterations like flattening of the condyle, erosions, and evolve to severe lesions, like destruction of the head of the condyle. We report a case of male patient who had destruction of both condyles, as a result from juvenile idiopathic arthritis. Proposed mechanisms to explain the juvenile idiopathic arthritis was reviewed. In this report the patient did not have pain or inflammatory process, and the temporomandibular diseases was the only manifestation.

RESUMO Artrite idiopática juvenil é um termo usado para incluir toda artrite infantil crônica de etiologia desconhecida. É caracterizada por uma inflamação crônica, que persiste por pelo menos 6 semanas, com início antes dos 16 anos de idade. As características presentes são sinovite crônica, artralgia, mobilidade articular diminuída em pelo menos uma articulação, e erosão com destruição da cartilagem e do osso subcondral, podendo ser associada ou não com o envolvimento sistêmico, de acordo com cada subtipo da doença. Durante o processo patológico, a articulação temporomandibular pode ser envolvida pela artrite idiopática juvenil, resultando em disfunção mandibular severa, com maior frequência em pacientes do sexo feminino. Inicialmente, estas lesões podem mostrar pequenas alterações, como achatamento do côndilo e erosões, e evoluir para lesões graves, como a destruição da cabeça do côndilo. Relatou-se o caso de um paciente do sexo masculino, que apresentou destruição de ambos os côndilos, como resultado da artrite idiopática juvenil. Os mecanismos para explicar a artrite idiopática juvenil foram revisados na literatura. Neste relato de caso, o paciente não apresentou dor e nem processo inflamatório, sendo o comprometimento da articulação temporomandibular a única manifestação.

Osteoporose induzida por glicocorticoides: expressão salivar de biomarcadores ósseos em pacientes submetidos à corticoterapia prolongada e sua correlação radiomorfométrica / Glucocorticoid-induced osteoporosis: salivary expression of bone turnover biomarkers and radiomorphometric analysis in long-term corticotherapy

A osteoporose, alteração osteometabólica crônico-degenerativa, de etiologia multifatorial, caracteriza-se pela redução da densidade mineral óssea, na qual observa-se a deterioração da microarquitetura óssea, com consequentes alterações nas propriedades físicas e quantitativas do esqueleto humano, tornando-o frágil e suscetível ao desenvolvimento de fraturas. A doença é classificada em primária e secundária, de acordo com sua etiopatogênese, sendo a osteoporose induzida por glicocorticoides (OPIG) a mais incidente dentre as tipologias secundárias. Evidencia-se alterações microarquiteturais ósseas, resultantes do regime crônico de altas doses medicamentosas, sendo seu diagnóstico realizado a partir da análise quantitativa da massa óssea pelo exame padrão densitometria óssea por absorciometria por dupla emissão de raios X. Não obstante, ainda se perpetua como um grande desafio às equipes multidisciplinares de saúde, caracterizando-se como uma técnica de alto custo e de acesso limitado a maior parte da população. Com o intuito de implementar abordagens menos invasivas e mais acessíveis no rastreio de osteoporose induzida por glicocorticoides, o presente estudo propôs analisar o impacto da corticoterapia prolongada pela avaliação bioquímica salivar comparativa de biomarcadores ósseos, associada ao estudo radiomorfométrico de radiografias panorâmicas de mandíbula, pelo índice mandibular cortical (IMCo), em dois tempos distintos. Nossa investigação observou reduções estatisticamente relevantes, em relação aos dados densitométricos de pacientes submetidos à corticoterapia prolongada, os quais, um ano após a instituição medicamentosa (T1), resultaram em valores de T-score de coluna e femoral significativamente alterados (p<0,0001 e p=0,0122, respectivamente), sendo que mais da metade (56%) dos pacientes apresentou redução da densidade mineral óssea, quando comparado ao início da corticoterapia (p=0,0002). O impacto do regime terapêutico prolongado refletiu significativamente no índice de massa corpórea dos doentes (p=0,0156). A partir da aferição do índice mandibular cortical em radiografias panorâmicas dos participantes, pôde-se observar diferença estatisticamente significante (p<0,0001), entre os dois tempos avaliados, e uma forte correlação entre si (rs=0,7952); tal como correlação positiva entre o índice mandibular e a classificação densitométrica instituída pela Organização Mundial da Saúde (T0, p=0,0443 e, em T1, p=0,3266). Adicionalmente, por meio do imunoensaio Luminex®, avaliamos a expressão salivar dos biomarcadores relacionados ao turnover ósseo Osteoprotegerina, Vitamina D, Osteopontina, Col1A1 e RANK-L entre o grupo de doentes e em controles saudáveis pareados, em T1. O fluido salivar detectou a expressão de todos os cinco marcadores, sendo observado diferença estatística para Osteoprotegerina (p <0,0001), Vitamina D BP (p = 0,0274) e TRANCE/RANK L (p <0,0001). Ademais, a correlação entre a expressão salivar e sérica, no próprio grupo de doentes, evidenciou diferença estatística significativa em todos os marcadores (p <0,0001), com exceção ao TRANCE/RANK L (p <0,9421). A aferição de alterações ósseas, por meio do índice mandibular cortical, mostrou-se associada à densidade mineral óssea vertebral e femoral, sugerindo o papel da radiografia panorâmica como indicador de modificações da massa óssea, sendo uma ferramenta auxiliar à diagnose; porém, não substituível à densitometria óssea. A saliva mostrou-se como uma alternativa biológica aos demais fluidos corporais, na detecção de alterações sistêmicas pertinentes ao metabolismo ósseo, resultantes da corticoterapia crônica, em indivíduos com pênfigo vulgar.

Chronic Suppurative Osteomyelitis of the Mandible Treated with Antibiotics Complemented with Surgical Treatment: A Case Report / Osteomielitis Crónica Supurativa en Mandíbula Tratada con Antibióticos y Cirugía: Reporte de Caso

ABSTRACT: Osteomyelitis is an infection that affects bone and bone marrow, it occurs due to inoculation of microorganisms either directly or by continuous accumulation through a hematogenous way. Female patient, 64 years old, presenting an increase of volume of the parotid masseteric region and right submandibular region, with approximately two weeks of evolution, which had a slightly fluctuating, hyperemic and hyperthermic indurated consistency; the patient complained of severe pain. CT scan and biopsy was indicated. It is imperative to identify the causative agent; the use of antibiotics must be complemented by surgical treatment to eliminate the possibility of a remaining infection.

RESUMEN: La osteomielitis es un proceso infeccioso que afecta al hueso y medula ósea y que se produce debido a la inoculación de microorganismos ya sea de manera directa, por continuidad o bien por medio de la vía hematógena. Paciente femenino de 64 años de edad que presentaba aumento de volumen en región submandibular derecha refiriendo dolor intenso con evolución de 2 semanas aproximadamente, el cual era de consistencia indurada ligeramente fluctuante, hiperémico e hipertérmico; la paciente se quejaba de dolor intenso, se indicó TC y biopsia. En estos casos para tener éxito en el tratamiento el uso de antibióticos debe complementarse con desbridamiento quirúrgico, aunado a un seguimiento estrecho para descartar la posibilidad de una infección remanente.

Cronología de la erupción dentaria permanente en nuestra población actual: correlación entre edad dental y edad cronológica en la población de la ciudad de La Plata / Chronology of permanent tooth eruption in our current population: correlation between dental age and chronological age in a population from La Plata city

La erupción dentaria es, indudablemente, un indicador de evolución biológica del organismo humano. Determinar la edad evolutiva del individuo puede tener particular valor, ya que no siempre la referencia a la cronología temporal es un recurso válido para interpretar el real estado de madurez de la persona. Son muchas las ramas de las ciencias médicas donde es muy importante lograr precisar la edad de una persona. La cronología de la erupción está condicionada por factores genéticos, como la raza y el sexo y a factores sociales y ambientales, como el estado nutricional, el tipo de alimentación y el clima. La población de la ciudad de La Plata y sus aledaños ha sufrido, en los últimos años, numerosos cambios, particularmente en su composición étnica y cultural. Biológicamente, la cruza de etnias puede haber incidido en la evolución de la cronología de la dentición, así como la modificación de determinadas costumbres alimentarias incorporadas. Existen tablas para evaluar el desarrollo del niño, basadas en parámetros clínicos unas y otras en parámetros radiográficos. Es importante conocer la concordancia o no entre las tablas basadas en los diferentes criterios de estudio. El objetivo de este trabajo fue comparar la edad cronológica y dentaria de una población infantil de la ciudad de La Plata, como base de datos para el tratamiento clínico. Se analizaron 199 radiografías panorámicas de niños entre 5 y 12 años. Las radiografías se agruparon según las etapas propuestas por Duterloo. En cada uno de los grupos se estableció, para cada radiografía, la edad dentaria del individuo, comparándola con la edad cronológica. Se establecieron las coincidencias y diferencias entre los valores obtenidos. Los resultados de los datos observados a partir de la población infantil estudiada permiten inferir que la edad dentaria difiere significativamente de la edad cronológica (p<0.05).

The dental eruption is undoubtedly an indicator of the biological evolution of the human organism. Determining the evolutionary age of the individual may have particular value, since not always the reference to the temporal chronology is a valid resource to interpret the real state of maturity of the person. There are many branches of the medical sciences where it is very important to achieve the age of a person. The chronology of the eruption is conditioned by genetic factors such as race and sex and social and environmental factors, such as nutritional status, type of diet and climate. The population of the city of La Plata and its surroundings has suffered, in recent years, many changes, particularly in its ethnic and cultural composition. Biologically, the ethnic cross may have influenced the evolution of the chronology of the dentition, as well as the modification of certain embodied food customs. There are tables to evaluate the development of the child, based on clinical parameters on radiographic parameters. It is important to know the concordance or not between the tables based on the different study criteria. The objective of this study was to compare the chronological and dental age of a child population in the city of La Plata, as a database for clinical treatment. We analyzed 199 panoramic radiographs of children between 5 and 12 years old. The radiographs were grouped according to the stages proposed by Duterloo. In each of the groups, the individual's dental age was established for each radiograph, comparing it with chronological age. The coincidences and differences between the obtained values ​​were established. The results of the data observed from the studied child population allow us to infer that tooth age differs significantly from chronological age (p <0.05).

Mandibular osteonecrosis induced by bisphosphonates in a carrier of chronicle kidney disease / Osteonecrosis mandibular inducida por bifosfonatosen un portador de enfermedad renal crónica

he bisphosphonates are synthetic substances of inorganic pyrophosphate that havebeen the basis of treatment of patients with osteolytic diseases, such as multiple myeloma, malignanthypercalcemia, Paget's disease, or patients with bone metastases. Its main pharmacological effect is inhibitionof bone resorption caused by osteoclasts, which have a reduced function. Their adverse effects are infrequentbut include pyrexia, impaired renal function, hypocalcemia, and more recently, maxillo-mandibular ostenecroseinduced bofosfonatos. In this report we describe a clinical case of jaw osteonecrosis induced by bisphosphonatesin patient with chronic kidney disease and the treatment protocol performed

Los bisfosfonatos son sustancias sintéticas de pirofosfato inorgánico que han sido la base del tratamiento de pacientes con enfermedades osteolíticas, como mieloma múltiple, hipercalcemia maligna, enfermedad de Paget o pacientes con metástasis ósea. Su principal efecto farmacológico es la inhibición dela resorción ósea causada por osteoclastos, que tienen una función reducida. Sus efectos adversos son infrecuentes, pero incluyen pirexia, deterioro de la función renal, hipocalcemia y, más recientemente, indujo inducido por bicosfonatos maxilomandibular. En este informe se describe un caso clínico de osteonecrosis mandibular inducida por bifosfonatos en pacientes con enfermedad renal crónica y el protocolo de trata-miento realizado.

Avaliação clínica e radiográfica de implantes curtos: estudo retrospectivo no período de 7 anos / Clinical and radiographic evaluation of short implants: retrospective study for a period of 7 years

Áreas edêntulas com severa reabsorção óssea têm sido reabilitadas com próteses fixas instaladas sobre implantes curtos, evitando que os pacientes sejam submetidos a cirurgias de reconstrução óssea. Este estudo retrospectivo descreve o comportamento de implantes curtos avaliados em um período de 7 anos. A amostra foi composta por 70 pacientes, de ambos os gêneros, que receberam 136 implantes, de 6 ou 8mm de comprimento (Straumann® bone level e tissue level standard plus) sobre os quais foram instaladas próteses unitárias e múltiplas, cimentadas e parafusadas. Foram realizadas avaliações clínicas e radiográficas mensurando a estabilidade do implante por frequência de ressonância, perda óssea marginal por meio de radiografias panorâmicas, índices de placa e de sangramento marginal, taxas de sobrevivência do implante e da prótese. Dois implantes instalados na mandíbula foram perdidos, resultando em uma taxa de sobrevivência de 98,3%. A taxa de sobrevivência das próteses foi de 100%; a média de perda óssea foi de - 0,28mm; a estabilidade média dos implantes foi de 76,515 ISQ; as médias dos índices de placa e de sangramento foram de 32,83% e 33,21%, respectivamente. A estabilidade do implante foi maior na mandíbula que na maxila (p = 0,006). Os resultados obtidos nesta pesquisa, possibilitam afirmar que os implantes curtos podem ser utilizados com segurança dentro de suas indicações específicas.(AU)

Edentulous areas with severe bone resorption have been rehabilitated with fixed prostheses installed on short implants, avoiding surgeries of bone reconstruction. This retrospective study describes the behavior of short implants evaluated during 7 years. The sample consisted of 70 patients, of both genders, who received 136 implants, 6 or 8mm in length (Straumann® bone level and tissue level standard plus) on which single and multiple, cemented and screwed prostheses were installed. Clinical and radiographic evaluations were performed by measuring implant stability by resonance frequency, marginal bone loss by panoramic radiographs, plaque and marginal bleeding rates, the implant and prostheses survival rates. Two implants installed in mandible were lost, resulting in a survival rate of 98,3%. The prostheses survival rate was 100%; mean bone loss was -0,28mm; mean implants stability was 76,52 ISQ; mean plaque and bleeding indexes were 32,83% and 33,21%, respectively. The implant stability was higher in the mandible than in the maxilla (p = 0.006). The results obtained in this research make it possible to state that short implants can be used safely within their specific indications.(AU)

The mental foramen I: radiographic study of the anterior-posterior position and shape in Iraqi population / Foramen mental I: estudio radiográfico de su posición antero-posterior y forma en población iraquí

Accurate information regarding the horizontal location and shape of the mental foramen can have clinical significance, such as reducing complications that may occur during maxillofacial surgical procedures involving the mental area. Geographic variations were reported in these variables. The aim was to study the horizontal position and shape of the mental foramen, as seen on panoramic radiographs of an Iraqi sample, to assess difference in these variables between sexes and age groups, and to assess symmetry of the mental foramen. 518 panoramic radiographs of a random Iraqi sample (257 males, 261 females, average age=46.5 years) were evaluated with regard to the horizontal location, shape and symmetry of the mental foramina. The area between the long axes of the two mandibular premolars, and the round type were the most frequent horizontal location and shape of mental foramen, respectively. Age advancement was found to be associated with an increase in the frequency of more posterior positioning and irregular shape. The horizontal position and shape were asymmetrical in 21.6% and 31.6% of cases, respectively. The Symmetry in horizontal location and shape of mental foramina were found statistically significant between sexes (P=0.041), and between young and old age groups (P=0.001), respectively. The most common horizontal location and shape of the mental foramen on panoramic radiographs in this group are between the two premolars, and the round type, respectively. This is in consistence with the findings of previous studies on other populations. The mental foramina have usually symmetrical horizontal locations and shapes.

Información precisa sobre la ubicación horizontal y forma del foramen mental puede tener importancia clínica en la reducción de complicaciones durante procedimientos quirúrgicos maxilofaciales que involucran el área mental. Fueron reportadas variaciones geográficas en relación a estas variables. El objetivo fue estudiar la posición horizontal y forma del foramen mental, a partir de 518 radiografías panorámicas de una muestra aleatoria en sujetos de Irak (257 varones, 261 mujeres; edad media= 46,5 años), quienes fueron evaluados con respecto a la posición horizontal, forma y la simetría de los forámenes mentales. En individuos de edad avanzada se encontró una asociación con un aumento en la frecuencia de un posicionamiento posterior y con forma irregular. La posición horizontal y forma del foramen fueron asimétricos en 21,6% y 31,6% de los casos, respectivamente. La diferencia hallada en relación a la simetría en posición horizontal y forma de los forámenes mentales fue estadísticamente significativa entre sexos (p=0,041), y entre los grupos de edad jóvenes y mayores (P=0,001), respectivamente. Se encontró con mayor frecuencia la posición horizontal entre los ejes longitudinales de los dos premolares mandibulares, y la forma circular, en relación a la posición antero-posterior y forma del foramen, respectivamente. Estos fueron resultados similares a estudios anteriores sobre otras poblaciones. Los forámenes mentales son simétricos, respecto a su ubicación horizontal y su forma.

Digital panoramic radiography for diagnosis of the temporomandibular joint: CBCT as the gold standard

Three-dimensional imaging modalities have been reported to be more accurate than panoramic radiographs (PR) for the assessment of bone components of the temporomandibular joint (TMJ). No exact prior information is available that demonstrates which specific limitations occur in terms of TMJ diagnosis when using PR for this purpose. This study aimed to assess the clinical validity of digital panoramic radiography (DPR) when diagnosing morphological disorders of the TMJ using cone-beam computed tomography (CBCT) images as the gold standard. A sample composed of TMJ images (N = 848), including 212 DPR and 212 CBCT images obtained from the same patient, was used to assess any morphological changes in the TMJ. Four appraisers diagnosed all of the DPR images, whereas the CBCT images were used to establish the gold standard. The reliability of each appraiser’s response pattern was analyzed using the Kappa test (κ), and diagnostic tests were performed to assess each appraiser’s performance using a significance level setting of 5% (α = 0.05). Reliability of each appraiser’s response pattern compared to the gold standard ranged from a slight-to-moderate agreement (0.18 ≤ κ ≤ 0.45); and among the different appraisers, the response pattern showed a fair agreement (0.22 ≤ κ ≤ 0.39). Diagnostic tests showed a wide range among the different possible morphological changes diagnosed. DPR does not have validity when diagnosing morphological changes in the TMJ; it underestimates the radiological findings with higher prevalence, and thus, it cannot be used effectively as a diagnostic tool for bone components within this region.

Impact of cone-beam computed tomography on implant planning and on prediction of implant size

The aim was to investigate the impact of cone-beam computed tomography (CBCT) on implant planning and on prediction of final implant size. Consecutive patients referred for implant treatment were submitted to clinical examination, panoramic (PAN) radiography and a CBCT exam. Initial planning of implant length and width was assessed based on clinical and PAN exams, and final planning, on CBCT exam to complement diagnosis. The actual dimensions of the implants placed during surgery were compared with those obtained during initial and final planning, using the McNemmar test (p < 0.05). The final sample comprised 95 implants in 27 patients, distributed over the maxilla and mandible. Agreement in implant length was 50.5% between initial and final planning, and correct prediction of the actual implant length was 40.0% and 69.5%, using PAN and CBCT exams, respectively. Agreement in implant width assessment ranged from 69.5% to 73.7%. A paired comparison of the frequency of changes between initial or final planning and implant placement (McNemmar test) showed greater frequency of changes in initial planning for implant length (p < 0.001), but not for implant width (p = 0.850). The frequency of changes was not influenced by implant location at any stage of implant planning (chi-square test, p > 0.05). It was concluded that CBCT improves the ability of predicting the actual implant length and reduces inaccuracy in surgical dental implant planning.

Avaliação da densidade mineral óssea por meio da radiografia panorâmica: modificadores e determinantes no resultado / Evaluation of bone mineral density by means of panoramic radiography: modifiers and determining the result

A osteoporose tem sido apontada como grave problema de saúde pública, que compromete a qualidade de vida dos seus portadores. Um dos principais fatores que influencia na prevenção à fraturas provenientes dessa enfermidade é o diagnóstico precoce. O diagnóstico das alterações morfológicas da mandíbula por meio de radiografias panorâmicas (RP) é um método barato, simples e indicado para o rastreamento da desmineralização óssea que mostrou estar associado às alterações sistêmicas. O presente estudo descritivo-analítico objetivou avaliar se existem e quais são as variáveis que podem interferir na determinação do diagnóstico por meio das RPs. Foram analisados dados sócio-biológicos, radiografias panorâmicas e densitometrias ósseas (DO) de um total de 435 pacientes. A análise das RPs foi realizada por meio do Índice Panorâmico Quantitativo e Qualitativo (IPQQ), estabelecido em outra parte desta pesquisa. Essas observações foram então relacionadas aos resultados da DO e às variáveis coletadas no questionário de dados sócio-biológicos. A análise das RPs mostrou estar correlacionada com a DO (kappa = 0,7) e mostrou ainda que pode ser influenciada pelo uso de bisfosfonatos ( p = 0,0137), renda ( p = 0,0264), e perda dentária representada pelas variáveis uso de prótese parcial removível ( p = 0,0249) e prótese parcial fixa ( p = 0,0320). O presente estudo propõe ainda outras investigações conduzidas com desenhos mais rigorosos, para compreensão do problema que ainda guarda muitas lacunas...

Osteoporosis has been identified as a serious public health problem affecting patients' life quality. One of the major factors that influences fractures prevention from this disease is early diagnosis. The diagnosis of mandible morphological changes using panoramic radiographs (PR) is an inexpensive, simple method suitable for screening bone demineralization associated with systemic changes. This descriptive- analytical study aimed to evaluate whether there are and what are the variables that can interfere in the determination of PRs' diagnosis. Socio-biological data, PR and bone densitometry (BO) of 435 patients were analyzed. The analysis was performed by RPs' Quantitative and Qualitative Panoramic Index (QQPI) previously established in another part of this research. These observations were then related to BO results and variables collected from socio-biological data questionnaire. The PR analysis were correlated with BO (kappa = 0.7) and could be influenced by the use of bisphosphonates (p = 0.0137), income (p = 0.0264), and tooth loss, represented by the variables: use of removable partial dentures (p = 0.0249) and use of fixed partial denture (p = 0.0320). This study also suggests the conduction of more rigorous designs researches to understand this problem that still has many gaps...

Radiographic evaluation of the dental condition of elderly people treated at a Brazilian public university

AIM: To assess the dental status of elderly patients examined in the clinical dentistry course of a Brazilian public university. METHODS: An observational and descriptive study based on the analysis of panoramic radiographs. The sample consisted of 60 elderly patients who met the inclusion criteria. Two observers who had been trained in appropriate conditions performed the radiographic analysis. Data were stored in a specific form, recorded in a database and analyzed using descriptive statistics (measures of central tendency and variability) and inferential statistics (Mann-Whitney U test, Kruskal-Wallis test, Chi-square analysis and calculation of the Cramer's V coefficient). RESULTS: Most patients had at least one tooth in the oral cavity (71.7%), while 28.3% were totally edentulous, an average of 10.5 teeth per individual. The average number of teeth was 11.36 in males and 9.89 in females. The number of healthy teeth was 328 (5.47 per patient). In this study, 88.3% of the subjects had periodontal bone loss, with prevalence of moderate (35.0%) and severe (28.3%) bone loss. CONCLUSIONS: Given the high incidence of edentulous individuals, the high number of restored teeth and poor periodontal conditions, it is concluded that the overall oral health status of the evaluated elderly subjects is poor.

Ameloblastoma: report of two cases and a brief literature review / Ameloblastoma: presentación de dos casos y una breve revisión de la literatura

Ameloblastoma is an uncommon odontogenic neoplasm that accounts for approximately 10 percent of all tumors originating from gnathic bones. Although its growth is localized, the tumor can also be infiltrative and persistent; however, its behavior is usually benign. The mandible is the most commonly affected site, and ameloblastoma is most frequently diagnosed between the fourth and fifth decades of life. In addition to a brief review of the literature, the present study discusses the clinical, imaging, histopathological and prognostic characteristics of these tumors by presenting two case reports. In these cases, the patients were aged 40 and 66 years, of different sexes and ethnicities and presented with the same complaint regarding localized and asymptomatic swelling. Both cases occurred in the posterior region (but on opposite sides) of the mandible. The patients were initially subjected to clinical examination and imaging of the face, followed by incisional biopsy to confirm (in both cases) the diagnosis of multicystic intraosseous ameloblastoma with a plexiform pattern. Both patients were treated by wide resection of the lesion (with safety margins), and only one patient experienced tumor recurrence. After 42 and 68 months of follow-up, the patients are still alive and show no signs of recurrence. Clinical and imaging findings aid in the differential diagnosis of ameloblastomas; however, histopathological evaluation is essential for its definitive diagnosis. Early diagnosis and precise detection of the borders to provide adequate safety margins during the surgical resection of the tumor are necessary to achieve successful treatment and recurrence-free survival for solid ameloblastomas.

El ameloblastoma es un tumor odontogénico infrecuente que representa aproximadamente 10 por ciento de todos los tumores que se originan a partir del maxilar y mandíbula. Aunque su crecimiento es localizado, el tumor puede ser infiltrante y persistente, y su comportamiento suele es benigno. La mandíbula es el sitio más comúnmente afectado, y el ameloblastoma se diagnostica con más frecuencia entre la cuarta y quinta década de la vida. Junto con una breve revisión de la literatura, el presente estudio analiza los datos clínicos, imágenes, características histopatológicas y pronóstico de estos tumores mediante la presentación de dos casos. En estos casos, los pacientes tenían entre 40 y 66 años, eran de diferentes sexos y grupos étnicos, que presentan la misma queja en relación con aumento de volumen localizado y asintomática. Ambos casos ocurrieron en la región posterior (pero en lados opuestos) de la mandíbula. Los pacientes fueron sometidos inicialmente a un examen clínico e imagenológico, seguido de la biopsia incisional para confirmar (en ambos casos) el diagnóstico de ameloblastoma multiquístico intraóseo tipo plexiforme. Ambos pacientes fueron tratados con amplia resección de la lesión (con márgenes de seguridad), y sólo un paciente presentó recurrencia del tumor. Después de 42 y 68 meses de seguimiento, los pacientes están vivos y sin signos de recurrencia. Los resultados clínicos e imagenológicos ayudan en el diagnóstico diferencial del ameloblastomas, sin embargo, la evaluación histopatológica es esencial para su diagnóstico definitivo. El diagnóstico prematuro y la precisa detección de las márgenes de la lesión proporcionan márgenes de seguridad adecuadas durante la resección quirúrgica del tumor y son necesarios para lograr el éxito del tratamiento y la supervivencia libre de recurrencia en los ameloblastomas sólidos.

Oral manifestations and radiographic changes in the jaw-bones of patients with end-stage renal disease onmaintenance hemodialysis: a descriptive study / Estudo descritivo das manifestações bucais e alterações radiográficas em maxilares de pacientes com doençarenal terminal e sob hemodiálise

Objectives: The purpose of the present study was to assess the oral manifestations and radiographic changes in the jawbones of patients undergoing hemodialysis, diagnosed with end-stage renal disease (ESRD). Methods: Forty patients on maintenance hemodialysis were clinically examined for oral manifestations and evaluated for radiographic changes in the jaws with panoramic and intra-oral periapical radiographs. Results were expressed as Percentage. Results: Out of 40 patients, 37 patients (92.5%) showed at least one or more oral manifestations. The most common oral manifestations were mucosal pallor (70%), xerostomia (57.5%), petechiae and ecchymoses (37.5%), and less common were taste alterations (15%), uremic odor (7.5%), coated tongue (10%) and mucosal pain (2.5%). Radiographic changes seen were loss of lamina dura (22.2%), altered trabecular pattern (5.5%), multiple radiolucent lesions (5%), and pulp calcification (2.7%). Conclusions: Most of the patients presented with oral signs and symptoms. However it was observed that patients demonstrating radiographic changes were mostly those who were on dialysis for a relatively long duration.

Objetivos: O objetivo do presente estudo foi avaliar as manifestações orais e alterações radiográficas nos maxilares de pacientes submetidos à hemodiálise e com diagnóstico de doença renal em estágio terminal (DRET). Métodos: 40 pacientes em hemodiálise de manutenção foram examinados clinicamente e avaliados radiograficamente por meio de radiografias panorâmicas e periapicais em busca de manifestações orais nas mandíbulas. Resultados: Dos 40 pacientes, 37 pacientes (92,5%) apresentaram pelo menos uma ou mais manifestações orais. As manifestações orais mais comuns foram: palidez da mucosa (70%), xerostomia (57,5%), petéquias e equimoses (37,5%); e menos comuns: alterações do paladar (15%), odor urêmico (7,5%), língua saburrosa (10%) e mucosa dolorida (2,5%). As alterações radiográficas observadas foram a perda da lâmina dura (22,2%), padrão trabecular alterado (5,5%), lesões radiolúcidas múltiplas (5%) e calcificação pulpar (2,7%). Conclusões: A maioria dos pacientes apresentava sinais e sintomas orais. Entretanto, foi observado que os pacientes demonstrando alterações radiográficas foram principalmente aqueles que estavam em diálise por um período relativamente longo.

Fratura patológica da mandíbula associada a tumor marrom do hiperparatireoidismo / Pathological fracture of the mandible associated with brown of hyperparathyroidism

O hiperparatireoidismo (HPT) secundário é uma complicação encontrada na insuficiência renal crônica, sendo o tumor marrom uma das manifestações tardias dessa condição. O tumor marrom é uma lesão óssea, com características benignas, decorrente da secreção excessiva de paratormônio. A correção do HPT leva à significativa regressão ou até ao desaparecimento completo do tumor marrom, não sendo geralmente necessário tratamento cirúrgico para a lesão. No entanto, quando não realizado o controle metabólico, sua expansão pode provocar fraturas patológicas, o que se observa também nos maxilares, levando o paciente a um comprometimento estético e funcional do sistema estomatognático. Relatamos aqui um caso clínico de fratura patológica da mandíbula de um paciente portador de tumor marrom do HPT secundário a insuficiência renal crônica