Lesiones perirradiculares persistentes: revisión narrativa / Persistent periradicular lesions: a narrative review

La persistencia de lesiones perirradiculares luego del tra- tamiento endodóntico es un problema que requiere del clínico un conocimiento cabal de la histofisiología y de la histopato- logía del sistema de conductos radiculares del tejido pulpar y de los tejidos perirradiculares (periodonto y hueso); además de considerar siempre la posible existencia de enfermedades sistémicas que también pueden actuar como factores de in- fluencia. La presencia de bacterias remanentes a posteriori del tratamiento es considerada como una de las causas principales y más frecuentes para la perpetuación de las lesiones perirra- diculares. Sin embargo, existen otros factores causales, como la existencia de conductos laterales o accesorios infectados y no tratados, la reabsorción dentinaria interna, intercomunica- ciones, cul-de-sacs o istmos; que representan áreas de difícil acceso durante la instrumentación e irrigación. Cuando la cau- sa original se localiza en la zona perirradicular, como en los casos de actinomicosis, reacciones a cuerpo extraño, cristales de colesterol (CRCo) y granulomas o quistes con alto conte- nido de CRCo, la indicación más adecuada es el retratamiento y la cirugía periapical como complemento (AU)

The persistence of periradicular lesions after endodontic treatment is a problem that requires the doctor to have a thor- ough knowledge of the histophysiology and histopathology of the root canal system, the pulp tissue and periradicular tis- sues (periodontium and bone); as well as always considering the possible existence of systemic alterations that can also be influencing factors. Persisting bacteria within the root canal system after treatment is one of the major and most frequent causes for the perpetuation of periradicular lesions. Howev- er, there are other possible causal factors such as the exist- ence of untreated lateral or accessory canals, internal dentin resorption, intercommunications, cul-de-sacs or isthmuses; areas that represent a difficulty in access during instrumen- tation and irrigation. If the original cause is located in the periradicular area, in cases like actinomycosis, foreign-body reactions, cholesterol crystals (CRCo) and granulomas or cysts with high content of CRCo, retreatment coupled with periapical surgery is the best approach to treatment (AU)

Retratamientos endodónticos: una realidad que preocupa / Endodontic retreatment: a worrying reality

Las evaluaciones radiográficas de tratamientos endodón- ticos realizadas por graduados muestran un alto porcentaje de procedimientos incorrectos. Esta circunstancia lleva a la rea- lización de un elevado número de retratamientos ortógrados y retrógrados, con los inconvenientes y desventajas que conlle- va recurrir a una reintervención endodóntica. Es responsabili- dad de los profesionales, docentes y autoridades universitarias y gubernamentales revertir esta situación que afecta a la salud bucal de la sociedad. En el presente editorial se proponen di- ferentes alternativas para intentar modificar este preocupante panorama (AU)

Radiographic evaluations of endodontic treatments per- formed by graduates show a high percentage of incorrect procedures. This circumstance leads to the performance of a high number of orthograde and retrograde retreatments, with the inconveniences and disadvantages that entails resorting to an endodontic reintervention. It is the responsibility of pro- fessionals, teachers, university and government authorities to reverse this situation that affects the oral health of society. In this editorial, different alternatives are proposed to try to modify this worrying outlook (AU)

Retratamiento y reparación de una perforación radicular. Informe clínico, radiográfico e histológico / Retreatment and healing of a case of root perforation. Clinical, radiographic and histological report

Objetivo: Describir los aspectos clínicos, radiográfi- cos e histológicos del retratamiento realizado en un segundo molar superior en el que se había producido previamente una perforación radicular durante el tratamiento original. Caso clínico: Un paciente masculino de 50 años con- currió a la consulta para realizar un retratamiento endodóntico en un segundo molar superior derecho. El examen radiográfi- co reveló la presencia de un tratamiento incompleto, un área radiolúcida periapical y una perforación radicular producida por un poste roscado insertado fuera del espacio del conducto mesio vestibular. Una vez retirado el poste, se selló la perfo- ración con Biodentine y se realizó el retratamiento. Luego de dos años, el paciente regresó a la consulta con dolor a la mas- ticación, localizado en el área correspondiente al segundo mo- lar superior derecho previamente tratado. Durante el examen clínico y radiográfico se detectó la presencia de una fractura vertical en la raíz palatina. A causa del severo compromiso radicular el molar fue extraído y derivado para su análisis his- tológico. El informe del laboratorio reveló que la perforación había sido reparada por medio de la aposición de un nuevo tejido calcificado y que el remanente periodontal adherido a la raíz se encontraba dentro de los límites normales. El presente caso clínico resalta la importancia que tiene el conocimiento cabal de la anatomía del sistema de conductos radiculares con el objeto de evitar errores de procedimiento que puedan influir negativamente en el pronóstico del tratamiento (AU)

Aim: To describe the clinical, radiographic and histo- logical aspects of the retreatment of a second upper molar in which root perforation had occurred during the original treatment. Clinical case: A 50-year old male was referred for endo- dontic retreatment of the right second maxillary molar. Radi- ographic examination revealed the presence of an incomplete root canal treatment, a radiolucent periapical area and a root perforation produced by a threaded post placed outside of the mesiobuccal root canal. After post removal, the root perfo- ration was sealed with Biodentine and the root canals were retreated. Two years later, the patient returned to the office com- plaining of severe pain during mastication, in the area of the previously retreated right second maxillary molar. Clinical and radiographic examination revealed the presence of a ver- tical fracture on the palatal root. Since this kind of root dam- age non-restorable, the tooth was extracted and submitted to histologic analysis. The laboratory report revealed that the perforation site had healed by the apposition of new calci- fied tissue, and that the remnants of periodontal tissue which persisted attached to the root were within normal limits. This clinical case highlights the importance of thorough knowl- edge of the anatomy of the root canal system in order to avoid procedural errors which may compromise the prognosis of the treatment (AU)

Uso da fototerapia como método complementar no retratamento endodôntico: revisões sistemáticas e meta-análise de ensaios clínicos / Use of phototherapy as a complementary method in endodontic reintervention: systematic reviews and meta-analysis of clinical trials

Este trabalho objetivou realizar duas revisões sistemáticas com as seguintes propostas: 1) Avaliar se a fototerapia com laser resultaria em menor dor pós-operatória (PP) em pacientes submetidos a reintervenção endodôntica; e 2) Avaliar se o uso da terapia fotodinâmica antimicrobiana (aPDT) seria eficaz na desinfecção de canais radiculares em casos de reintervenção endodôntica. As Revisões Sistemáticas foram registradas no PROSPERO (CRD42021243500 e CRD42021260013, respectivamente) e seguiram as diretrizes dos Itens de Relatório Preferenciais para Revisões Sistemáticas e Meta-análise (PRISMA). As buscas foram realizadas nas bases de dados eletrônicas PubMeb, Scopus, Web of Science, Embase, Web of Science, Clinical Trials e Cochrane Library e nos bancos de dados da literatura cinza. A qualidade metodológica e o risco de viés foram avaliados pela ferramenta Cochrane Risk of Bias para ensaios clínicos randomizados (RCT) e pelo qualificador NewcastleOttawa (NOS) para estudos não RCT (prospectivos). A análise da qualidade de evidência foi realizada com base na abordagem GRADE. A meta-análise foi realizada com o R software Meta package, utilizando um intervalo de confiança (IC) de 95%. Quanto aos resultados do Artigo 1: Cinco artigos foram incluídos para análise. Os estudos foram classificados como "baixo" risco de viés. Dos cinco estudos clínicos, quatro estudos mostraram uma diminuição significativa da PP após a reintervenção endodôntica nos grupos de fototerapia a laser quando comparados ao grupo controle, principalmente nos primeiros dias após a intervenção. A certeza de evidência foi classificada como baixa. Devido à alta heterogeneidade clínica entre os estudos, não foi possível realizar qualquer meta-análise. Apesar das limitações desta revisão sistemática, a fototerapia se mostrou uma alternativa promissora na redução e controle da PP na reintervenção endodôntica não cirúrgica. Nos resultados do Artigo 2, dez estudos atenderam aos critérios de elegibilidade e foram incluídos, sendo 8 utilizados na síntese quantitativa. A meta-análise mostrou que todos os dados dos estudos apresentaram diferença significativa antes e depois da terapia fotodinâmica antimicrobiana na redução da carga microbiana em infecções endondônticas secundárias (OR 0,15 [0,07; 0,32], p < 0,0001). No geral, os estudos apresentaram baixo risco de viés e a análise das evidências foi classificada como moderada. Sugere-se que a terapia fotodinâmica seja uma ferramenta benéfica e promissora, mostrando eficácia na redução da carga microbiana nos casos de reintervenção endodôntica. Em suma, a abordagem da utilização da fototerapia se demonstrou eficaz na diminuição da dor pós-operatória e na desinfecção dos canais radiculares, podendo ser uma terapia indicada nos casos de reintervenção endodôntica(AU)

This study aimed to carry out two systematic reviews with the following proposals: 1) Evaluate whether laser phototherapy would result in less postoperative pain (PP) in patients undergoing endodontic reintervention; and 2) Evaluate whether the use of antimicrobial photodynamic therapy (aPDT) would be effective in disinfection of root canals in cases of endodontic reintervention. Systematic Reviews were registered in PROSPERO (CRD42021243500 and CRD42021260013, respectively) and followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Metaanalysis (PRISMA). Searches were performed in the electronic databases PubMeb, Scopus, Web of Science, Embase, Web of Science, Clinical Trials and Cochrane Library and in the gray literature databases. Methodological quality and risk of bias were assessed by the Cochrane Risk of Bias tool for randomized clinical trials (RCT) and by the Newcastle-Ottawa (NOS) qualifier for non-RCT (prospective) studies. The analysis of the quality of evidence was performed based on the GRADE approach. The meta-analysis was performed using the R Meta package software, using a 95% confidence interval (CI). As for the results of Article 1: Five articles were included for analysis. Studies were classified as "low" risk of bias. Of the five clinical studies, four studies showed a significant decrease in PP after endodontic reintervention in the laser phototherapy groups when compared to the control group, mainly in the first days after the intervention. The certainty of evidence was rated low. Due to the high clinical heterogeneity between studies, it was not possible to perform any meta-analysis. Despite the limitations of this systematic review, phototherapy proved to be a promising alternative for the reduction and control of PP in conventional endodontic reintervention. In the results of Article 2, ten studies met the eligibility criteria and were included, being 8 used in the quantitative synthesis. The meta-analysis showed that all data from the studies showed a significant difference before and after antimicrobial photodynamic therapy in reducing the microbial load in secondary endodontic infections (OR 0.15 [0.07; 0.32], p < 0.0001). Overall, the studies presented a low risk of bias and the analysis of evidence was rated as moderate. It is suggested that photodynamic therapy is a beneficial and promising tool, showing efficacy in reducing the microbial load in cases of endodontic reintervention. In summary, the approach to the use of phototherapy has been shown to be effective in reducing postoperative pain and disinfection of root canals, and may be an indicated therapy in cases of endodontic reintervention(AU)

Application status and prospect of single-cone obturation technique with bioceramic sealers / 中华口腔医学杂志

Compared with cold lateral condensation and continuous wave of condensation which are classically used in clinical, newly emerging single-cone obturation technique is easy-to-operate as well as time-saving. Especially when combined with bioceramic root canal sealers of improved physicochemical and biological properties, single-cone obturation technique showed satisfactory short-term outcomes in clinical observations. However, difficulties still exist in avoiding the root canal overfilling and in operating the retreatment. Besides, the long-term effects of single-cone obturation with bioceramic sealers still remain unclear. This article makes an overview on the history and development of single-cone obturation ,and provides analysis of its pros and corns. Furthermore, we would also like to summarize its clinical application and look into its future improvements.

Alargamento do forame como complemento no tratamento endodôntico para regeneração de uma lesão periapical extensa: relato de caso / Foraminal enlargement as a complement in the endodontic treatment for the regeneration of an extensive periapical lesion. A case report

Introdução: O alargamento do forame refere-se ao alargamento mecânico intencional do forame para reduzir a carga bacteriana em uma área afetada frequentemente por infecções endodônticas além do limite da constrição apical. Objetivo: O objetivo do presente relato de caso é apresentar a técnica de alargamento do forame de um dente com lesão periapical extensa, como complemento do tratamento endodôntico e alternativa precoce à microcirurgia periapical. Métodos: É apresentado o caso de um incisivo lateral superior endodonticamente tratado, com uma extensa lesão periapical associada. Devido à história clínica e radiográfica, tempo decorrido desde o tratamento endodôntico inicial e alta probabilidade de áreas de reabsorção apical com biofilme extrarradicular, o retratamento endodôntico com alargamento do forame foi indicado como primeira opção, adiando a indicação de cirurgia endodôntica de acordo com a evolução. Resultados: Na avaliação de acompanhamento de dois anos, por exame de imagem, observou-se evolução clínica favorável ao retratamento, com aumento total da densidade óssea. O procedimento cirúrgico endodôntico complementar foi descartado. Conclusão: O alargamento do forame é uma alternativa complementar viável em casos de periodontite apical de longa duração com suspeita de biofilme no nível do forame. Pode ser considerado uma opção antes da indicação de retratamento endodôntico cirúrgico (AU).

Introduction: Foraminal enlargement refers to intentional mechanical enlargement of the foramen to reduce the bacterial load in an area frequently affected by endodontic infections beyond the limits of the apical constriction. The objective of this case report is to present the foraminal enlargement technique of a tooth with an extensive periapical lesion as a complement in the endodontic treatment and an early alternative to periapical microsurgery. Materials and methods: The case is presented of an endodontically treated upper lateral incisor with an extensive associated periapical lesion. Due to the clinical and radiographic history, the time elapsed since the initial endodontic treatment, and the high probability of areas of apical resorption with extra-radicular biofilm, endodontic retreatment with foraminal enlargement was indicated as the first option, postponing the indication for endodontic surgery according to evolution. Results: In the follow-up appointment at 2 years, a favorable clinical imaging evolution of retreatment was observed, with a total increase in bone density. The complementary endodontic surgical procedure was discarded. Conclusion: Foraminal enlargement is a viable complementary alternative in cases of long-term apical periodontitis with suspicion of biofilm at the foramen level. It can be considered an option before the indication of surgical endodontic retreatment (AU).

Retreatment of mesial roots of mandibular molars filled with resin-based and bioceramic sealers

Aim: The aim of this study was to evaluate, by micro-computed tomography (micro-CT) analysis, the remaining filling material during endodontic retreatment performed with Protaper retreatment without solvent. Methods: Forty mandibular molars were divided into two groups (n = 20) according to the sealer used in the obturation: the bioceramic TotalFill BC (TF) or the resin-based AH Plus (AHP). The specimens were scanned before instrumentation, after obturation and after filling removal. Only the mesial roots were analysed. The filling volumes and the remaining filling material were calculated in the entire root canal and in the cervical, middle and apical thirds. Results: The volume of obturation and the volume of remaining filling material in the entire root canal and in the cervical, middle and apical thirds of the canal between the groups were not statistically different (independent t-test, p > 0.05). In the AHP group, there was a higher percentage of remaining filling material in the middle third than in the cervical third (p < 0.05). Conclusion: The filling material could not be entirely removed from any specimen

Retratamento endodôntico e complementação cirúrgica em dente com fístula persistente: relato de caso / Endodontic retreatment and surgical complementation on a tooth with persistent fistula: case report

Introdução: O preparo químico-mecânico representa uma etapa fundamental, pois promove a antissepsia do complexo sistema de canais radiculares, viabilizando um ambiente biológico favorável para o processo de cura e reparo dos tecidos periapicais. Porém, insucessos podem acontecer em dentes tratados e retratados endodonticamente, sendo a intervenção cirúrgica frequentemente indicada nesses casos. Relato do caso: Paciente do sexo masculino, 32 anos de idade, melanoderma, apresentou-se à clínica-escola de uma faculdade de Odontologia em um município baiano, com queixa principal de "aparecimento de bolha na gengiva e gosto amargo na boca". Ao exame clínico, visualizou-se presença de restauração de resina composta nas faces mesial e palatina, bem como fístula intrabucal ativa na região de fundo de vestíbulo, próximo ao ápice do elemento #22. Por meio de exames clínico e radiográfico, testes de sensibilidade pulpar e rastreamento da fístula, foi estabelecido diagnóstico de tratamento endodôntico concluído, e periapical de abscesso apical crônico. Em seguida, houve indicação de retratamento endodôntico e duas sessões de medicação intracanal com hidróxido de cálcio, seguidas de uma intervenção cirúrgica exploratória. Resultados: O protocolo de tratamento proposto foi eficaz. Constatou-se sucesso clínico, com cicatrização da fístula intrabucal ativa, e radiográfico, com reparação dos tecidos periapicais, além do restabelecimento da estética e função dentária, com acompanhamento de 26 meses. O paciente encontra-se sob acompanhamento semestral. Conclusão: é necessário salientar a relevância de efetuar com segurança um planejamento e prognóstico endodôntico confiável e, igualmente, o acompanhamento do caso, com supervisão clínica e radiográfica periódica (AU).

Introduction: Biological chemical preparation repre- sents a fundamental step, as it promotes asepsis of the complex root canal system, enabling a biological environment favorable to the process of healing and repair of the periapical tissues. However, failures can occur in endodontic treatment and retreatment teeth, where surgical intervention is often indicated in these cases. Description: The patient, a 32-year old man, melanoderma, presented at the school clinic of a School of Dentistry in a city in Bahia, with a chief complaint of "blistering of the gums and bitter taste in the mouth." Clinical examination revealed the presence of composite resin restoration on the mesial and palatine surfaces, and an active intraoral fistula in the vestibular region near the apex of tooth 22. By means of clinical, radiographic, pulp sensitivity tests and sinus tracking, a diagnosis of completed endodontic treatment was established, and periapical diagnosis of a chronic apical abscess. Afterwards, endodontic retreatment was indicated, consisting of two sessions of intracanal medication with calcium hydroxide, followed by an exploratory surgical intervention. Results: The proposed treatment protocol was effective. Clinical and radiographic success with healing of the active intrabuccal fistula and repair of the periapical tissues, as well as reestablishment of esthetics and dental function, was verified, in a period of twenty six months follow-up. At present, the patient is being followed-up semi-annually. Conclusion: it is necessary to emphasize the importance of safely performing reliable endodontic planning and prognosis, as well as follow up of the case, with periodic clinical and radiographic control (AU).

Estudio comparativo de los tiempos registrados por los instrumentos TruNatomy y ProTaper Next para alcanzar la longitud de trabajo en conductos curvos simulados obturados con GuttaCore / Comparative study of the times recorded by the TruNatomy and ProTaper Next instruments to reach the working length in simulated curved canals filled with GuttaCore

Objetivo: Comparar el tiempo empleado por los instrumen- tos TruNatomy Medium y ProTaper Next X3 para penetrar hasta la longitud de trabajo la masa de obturaciones realizadas con Gut- taCore Primary y sellador en conductos curvos simulados. Materiales y métodos: Se prepararon 20 conductos curvos simulados con instrumentos rotatorios WaveOne Gold Primary y se obturaron con GuttaCore Primary y AH Plus. Las muestras fueron divididas en dos grupos de 10 cada uno. Grupo 1: El material de obturación fue penetrado hasta la lon- gitud de trabajo con instrumentos TruNatomy Medium. Gru- po 2: El material de obturación fue penetrado hasta la longitud de trabajo con instrumentos ProTaper Next X3. Se registraron los tiempos de penetración requeridos para cada grupo y los valores obtenidos fueron analizados mediante la prueba t de Student. Resultados: Los instrumentos ProTaper Next X3 pe- netraron la masa del material de obturación más rápidamente que los instrumentos TruNatomy MediumTM. Las diferencias observadas entre ambos instrumentos fueron estadísticamente significativas (P <0.01). Conclusión: Si bien los instrumentos ProTaper Next X3 y TruNatomy MediumTM penetraron la masa de Gutta- Core Primary de manera eficiente, ProTaper Next X3 penetró hasta la longitud de trabajo más rápidamente (AU)

Aim: Compare the time required by the instruments TruNatomy Medium and ProTaper Next X3 to penetrate up to the working length the mass of fillings made with GuttaCore Primary and sealant in simulated curved canals. Materials and methods: The simulated canals of 20 EndoTraining Blocks were prepared with WaveOne Gold Pri- mary and obturated with GuttaCore Primary and AH Plus. The sample was divided into two groups of 10 each. Group 1: The sealing material was penetrated up to working length with TruNatomy Medium. Group 2: The sealing material was penetrated up to working length with ProTaper Next X3. The penetration time was recorded in each group and the obtained values were statistically analyzed with the Student's t test. Results: ProTaper Next X3 instruments penetrated the sealing material mass faster than TruNatomy Medium. Statis- tically significant differences were observed between the two instruments (P <0.01). Conclusion: While the ProTaper Next X3 and TruNat- omy Medium penetrated the GuttaCore mass to the working length efficiently, the ProTaper Next X3 did it in less time (AU)

Efeito do laser de baixa intensidade como coadjuvante na reparação óssea de dente com perfuração radicular e lesão perirradicular: relato de caso clínico, com 12 anos de acompanhamento / Effect of low intensity laser supporting bone repair on a tooth with root perforation and periradicular lesion: case report and 12 years follow-up

Introdução: O laser em baixa intensidade apresenta propriedades que podem ser efetivas no tratamento endodôntico, como a capacidade reparadora, a atuação antimicrobiana e o auxílio à proliferação celular. Objetivo: Descrever, por meio do relato de um caso clínico, a ação do laser em baixa intensidade como coadjuvante na reparação óssea de uma perfuração radicular e lesão perirradicular em um elemento dentário com canais tratados, sendo realizado retratamento endodôntico apenas do canal mesiovestibular, utilizando-se hidróxido de cálcio como medicação intracanal e laser em baixa intensidade. Os demais canais não foram submetidos a retratamento, apesar de apresentarem lesão perirradicular. Resultados: O laser em baixa intensidade mostrou-se efetivo como auxiliar no processo de reparação óssea restituindo, ad integrum, o osso interradicular e as lesões perirradiculares das raízes mesial e distal após acompanhamento de 12 anos. Conclusões: O laser em baixa intensidade pode ser utilizado como coadjuvante ao tratamento de perfurações, demonstrando sucesso em longo prazo (AU).

Introduction: Low intensity laser has properties that may be effective in endodontic treatment, such as restorative capacity, antimicrobial performance and cell proliferation. Methods: This report describes the action of low intensity laser as an adjunct to bone repair of a root perforation and peri-radicular lesion in a tooth submitted to endodontic treatment, in which endodontic retreatment was performed only in the mesiobuccal canal using calcium hydroxide as intracanal medication and low level laser. The other canals were not submitted to retreatment, in spite of having peri-radicular lesions. Results: The low-intensity laser was effective as an adjunct to the bone repair process, restoring ad-integrum, interradicular bone and the peri-radicular lesions of the mesial and distal roots, after 12 years of follow-up. Conclusion: The laser at low intensity can be used as a coadjuvant to the treatment of perforations, demonstrating long-term success (AU).

Itinerário terapêutico de pessoas com tuberculose resistente e em retratamento / Itinerario terapéutico de personas con tuberculosis resistente y en retratamiento / Therapeutic itinerary for people with resistant tuberculosis under retreatment

Objetivo: analisar a percepção de pessoas com tuberculose sobre o itinerário terapêutico da tuberculose resistente e em retratamento. Materiais e método: pesquisa descritiva, com abordagem qualitativa, realizada com pessoas com tuber-culose resistente ou em retratamento por abandono ou recidiva. Os dados foram coletados por meio de entrevistas semiestruturadas, que, depois de transcritas, foram submetidas à análise de conteúdo e, posteriormente, analisadas à luz do referencial teórico sobre itinerário terapêutico. Resultados:na percepção das pessoas com tuberculose resistente ou em retratamento, evidenciou-se o pouco entendimento sobre a doença e a recidiva, principalmente quanto à causa. No itinerário terapêutico em busca dos serviços para atender às necessidades de saúde apontaram a centralização do atendimento no serviço hospitalar. A adesão esteve remetida ao abandono do tratamen-to anterior, à necessidade de voltar à rotina e ao medo de transmissão para os familiares. As ações de auto-cuidado se relacionaram à adesão ao tratamento, ao uso de equipamentos de proteção individual e à adoção de hábitos de vida mais saudáveis. Conclusões: os itinerários tera-pêuticos de pessoas com tuberculose aconteceram em diferentes níveis da atenção à saúde, especialmente nos centros especializados. Em cada serviço, analisaramse diferentes experiências quanto ao entendimento sobre a doença, ao tratamento e aos diferentes sentimentos durante o percurso do tratamento. Diante disso, os profissio-nais necessitam fazer uso de estratégias que considerem a complexidade do uso de múltiplos medicamentos, a necessidade de monitoramento da adesão e da atenção às comorbidades.

Objetivo: analizar la percepción de las personas con tuberculosis sobre el itinerario terapéutico de la tuberculosis resistente y en retratamiento. Materiales y método: investigación descriptiva, con enfoque cualitativo, realizada con personas con tuberculosis resistente o en retratamiento por abandono o recaída. Los datos fueron recolectados por medio de entrevistas semiestructuradas, que luego de ser transcritas fueron sometidas a análisis de contenido y posteriormente analizadas a la luz del marco teórico sobre itinerario terapéutico. Resultados: en la percepción de las personas con tuberculosis resistente o en retratamiento había poco conocimiento sobre la enfermedad y la recaída, especialmente en cuanto a la causa. En el itinerario terapéutico en busca de servicios para satisfacer las necesidades de salud, apuntaron a la centralización de la atención en el servicio hospitalario. La adherencia se relacionó con el abandono del tratamiento previo, la necesidad de volver a la rutina y el miedo a la transmisión a los familiares. Las acciones de autocuidado se relacionaron con la adherencia al tratamiento, el uso de equipos de protección personal y la adopción de hábitos de vida más saludables. Conclusiones: los itinerarios terapéuticos de las personas con tuberculosis tuvieron lugar en diferentes niveles de atención de salud, especialmente en centros especializados. En cada servicio se analizaron diferentes experiencias en cuanto a la comprensión de la enfermedad, el tratamiento y las diferentes sensaciones en la trayectoria del tratamiento. Por lo tanto, los profesionales deben hacer uso de estrategias que consideren la complejidad del uso de múltiples medicamentos, la necesidad de monitorear la adherencia y la atención a las comorbilidades

Objective: To study the perception of people with tuberculosis about the therapeutic itinerary of resistant tuberculosis and its retreatment. Materials and method:Descriptive research, with a qualitative approach, carried out with people with resistant tuberculosis or subject to retreatment due to abandonment or relapse. Data were collected through semi-structured interviews, which after being tran-scribed were submitted to content analysis, and, subsequently, analyzed in the light of the theoretical frame-work on therapeutic itinerary. Results: The perception of people with resistant tuberculosis or under retreatment shows little understand-ing about the disease and its relapse, especially regarding the cause of the disease. In the therapeutic itinerary in search of services to meet health needs, they pointed to the centralization of care in the hospital service. Adherence was related to the abandonment of previous treatment, the need to return to a routine, and fear of transmission to family members. Self-care actions were related to adher-ence to treatment, the use of personal protective equipment and the adoption of healthier lifestyle habits. Conclusions: Therapeutic itineraries of people with tuberculosis took place at different levels of health care, particularly in specialized centers. In each service, different experiences were examined regarding the under-standing of the disease, its treatment, and the different feelings involved during the treatment. Therefore, professionals should deploy strategies that consider the complexity of using multiple medications and the need to monitor adherence and existing comorbidities.

Surgical-orthodontic retreatment of a severe skeletal Class III malocclusion following an orthodontic camouflage

ABSTRACT Introduction: Class III malocclusions are some of the most difficult occlusal anomalies to be treated. Some patients with this condition may require orthognathic surgery, while others may be treated with dental camouflage. Proper patient assessment and selection remains critical in order to achieve favorable results. Objectives: This report outlines the case of an 18-year-old male who sought retreatment for a severe skeletal Class III dentofacial deformity after undergoing orthodontic camouflage treatment involving mandibular arch extractions. A treatment plan comprising dental decompensation and orthognathic surgery was implemented in order to achieve optimal facial and occlusal results. Results: After 28 months of treatment, skeletal and dental correction was achieved and facial features were significantly improved. The orthognathic surgery required a 20-mm sagittal maxillomandibular skeletal correction, combined with a 4-mm correction of the midlines and a 2-mm impaction of the maxilla. Conclusion: Dental compensation may be a risky treatment alternative for severe dentoskeletal discrepancies. In these patients, orthodontics combined with orthognathic surgery is the recommended treatment option.

RESUMO Introdução: As más oclusões de Classe III são uma das anomalias oclusais mais difíceis de serem tratadas. Alguns pacientes com essa condição podem precisar de cirurgia ortognática, enquanto outros podem ser tratados por meio da camuflagem ortodôntica. A correta avaliação e seleção do paciente para cada tipo de abordagem permanece uma decisão crítica para se obter resultados favoráveis. Objetivos: O presente artigo relata o caso de um paciente do sexo masculino, com 18 anos de idade, que procurou tratamento por causa de uma má oclusão esquelética severa de Classe III, após ter se submetido a camuflagem ortodôntica com extração de dentes inferiores. Um plano de tratamento envolvendo descompensação dentária e cirurgia ortognática foi implementado, com a finalidade de atingir resultados faciais e oclusais ideais. Resultados: Após 28 meses de tratamento, foi alcançada a correção esquelética e dentária, e as características faciais obtiveram uma melhora significativa. A cirurgia ortognática exigiu uma correção esquelética sagital bimaxilar de 20 mm, associada a 4 mm de correção das linhas médias e 2 mm de impacção da maxila. Conclusão: A compensação dentária pode ser um tratamento alternativo arriscado para discrepâncias dentoesqueléticas severas. Nesses pacientes, a Ortodontia associada à Cirurgia Ortognática é a opção de tratamento recomendada.

Multi-state outcome analysis of treatment interventions after failure of non-surgical root canal treatment: a 13-year retrospective study

Abstract Objective To examine the factors affecting the transitions through treatment interventions after failure of non-surgical root canal treatment (NS-RCT). Methodology Insurance enrollment and claim information for enrollees of Delta Dental of Wisconsin (DDWI), USA were analyzed for 438,487 initial NS-RCT procedures to determine the effect of initial provider type and other covariates on additional treatments (no additional treatment, nonsurgical retreatment, surgical retreatment and extraction). A multi-state model was created using the "mstate" R package. Transitions between the four states identified by Code on Dental Procedures and Nomenclature were analyzed. Cox proportional Hazards regression stratified by transition type was used to estimate the effect of provider type on the risk of each transition, adjusting for covariates. Results The overall survival rates for all teeth that were treated by NS-RCT was 82.8% [95% CI 82.57%, 83.11%] at 10 years. Approximately, 7% of cases changed from the first state of initial NS-RCT during the 13-year study period with ultimately 0.9%, 0.4% and 5% of cases receiving non-surgical retreatment, surgical retreatment or extraction, respectively. Teeth are more likely to be retreated non-surgically than surgically, and to be extracted than retreated. In general, the probability of a tooth having non-surgical retreatment was higher if the initial provider was not an endodontist (Hazard Ratio (HR)=3.2). Molars were more likely to be non-surgically retreated (HR=2.0) or extracted (HR=2.8) when compared to anterior teeth. The probability of non-surgical retreatment (HR=0.93) or extraction (HR=0.50) was lower when a crown was placed within 90 days after NS-RCT. Conclusion Most teeth remained in the same state after treatment with no additional treatment transitions. When a transition occurred, it was more likely to be an extraction. Type of provider, age, location of the tooth, gender, and time to placement of final restoration significantly influence treatment transitions.

Retratamento com surfactante em prematuros de muito baixo peso: preditores de risco e sua influência nos resultados neonatais / Retreatment with surfactant in very low birth weight preterm infants: risk predictors and their influence on neonatal outcomes

ABSTRACT Objective: To assess clinical predictors and outcomes associated to the need for surfactant retreatment in preterm infants. Methods: Retrospective cohort study, including very low birth weight preterm infants from January 2006 to December 2015 who underwent surfactant replacement therapy. Beractant was used (100 mg/kg), repeated every six hours if FiO2 ≥0.40. The subjects were classified into two groups: single surfactant dose; and more than one dose (retreatment). We evaluated maternal and neonatal predictors for the need of retreatment and neonatal outcomes associated to retreatment. Results: A total of 605 patients (44.5%) received surfactant; 410 (67.8%) one dose, and 195 (32.2%) more than one dose: 163 (83.5%) two doses and 32 (16.4%) three doses. We could not find clinical predictors for surfactant retreatment. Retreatment was associated to a greater chance of BPD in infants >1000 g (RR 1.78; 95%CI 1.30‒2.45) and ≤1000 g (RR 1.33; 95%CI 1.04‒1.70), in infants with gestational age<28 weeks (RR 1.56; 95%CI 1.12‒2.18) and ≥28 weeks (RR 1.50; 95%CI 1.17‒1.92), in neonates with early sepsis (RR 1.48; 95%CI 1.20‒1.81), and in infants not exposed to antenatal corticosteroids (RR 1.62; 95%CI 1.20‒2.17) Conclusions: We could not find predictor factors associated to surfactant retreatment. The need for two or more doses of surfactant was significantly related to bronchopulmonary dysplasia.

RESUMO Objetivo: Avaliar preditores clínicos e resultados associados à necessidade de retratamento com surfactante. Métodos: Coorte retrospectiva com prematuros de muito baixo peso, no período de janeiro de 2006 a dezembro de 2015, em uso de terapia de reposição de surfactante. O surfactante utilizado foi beractante (100 mg/kg), repetido a cada seis horas se FiO2≥0.40. Foram analisados dois grupos: dose única de surfactante e mais de uma dose (retratamento). Foram avaliados preditores maternos e neonatais para retratamento e resultados neonatais. Resultados: 605 pacientes (44,5%) receberam surfactante; 410 (67,8%) uma dose e 195 (32,2%) mais de uma dose: 163 (83,5%) duas doses e 32 (16.4%) três doses. Não foram encontrados fatores associados ao retratamento com surfactante. A displasia broncopulmonar (DBP) foi associada ao retratamento (p<0.01). A presença de retratamento aumentou a chance de ocorrência de DBP em neonatos >1000 g (RR 1,78; IC95% 1,30‒2,45) e ≤1000 g (RR 1,33; IC95% 1,04‒1,70), em recém-nascidos com idade gestacional <28 semanas (RR 1,56; IC95% 1,12‒218) e ≥28 semanas (RR 1,50; IC95% 1,17‒1,92), naqueles com sepse precoce (RR 1,48; IC95% 1,20‒1,81), e nos que não foram expostos ao corticoide antenatal (RR 1,62; IC95% 1,20‒2,17). Conclusões: Não encontramos fatores preditores associados à necessidade de retratamento. A necessidade de duas ou mais doses de surfactante está associada à displasia broncopulmonar.

Root canal retreatment: a retrospective investigation using regression and data mining methods for the prediction of technical quality and periapical healing

Abstract Objectives This study aimed to investigate patterns and risk factors related to the feasibility of achieving technical quality and periapical healing in root canal non-surgical retreatment, using regression and data mining methods. Methodology This retrospective observational study included 321 consecutive patients presenting for root canal retreatment. Patients were treated by graduate students, following standard protocols. Data on medical history, diagnosis, treatment, and follow-up visits variables were collected from physical records and periapical radiographs and transferred to an electronic chart database. Basic statistics were tabulated, and univariate and multivariate analytical methods were used to identify risk factors for technical quality and periapical healing. Decision trees were generated to predict technical quality and periapical healing patterns using the J48 algorithm in the Weka software. Results Technical outcome was satisfactory in 65.20%, and we observed periapical healing in 80.50% of the cases. Several factors were related to technical quality, including severity of root curvature and altered root canal morphology (p<0.05). Follow-up periods had a mean of 4.05 years. Periapical lesion area, tooth type, and apical resorption proved to be significantly associated with retreatment failure (p<0.05). Data mining analysis suggested that apical root resorption might prevent satisfactory technical outcomes even in teeth with straight root canals. Also, large periapical lesions and poor root filling quality in primary endodontic treatment might be related to healing failure. Conclusion Frequent patterns and factors affecting technical outcomes of endodontic retreatment included root canal morphological features and its alterations resulting from primary endodontic treatment. Healing outcomes were mainly associated with the extent of apical periodontitis pathological damages in dental and periapical tissues. To determine treatment predictability, we suggest patterns including clinical and radiographic features of apical periodontitis and technical quality of primary endodontic treatment.

Remoção de obturações endodônticas de Endosequence BC/CPoint em canais radiculares curvos usando instrumentos rotatórios ou reciprocantes / Removal of Endosequence BC/CPoint endodontic fillings in curved root canals using rotary or reciprocating instruments

Objetivo: O presente estudo usou micro-CT para avaliar a quantidade de material obturador remanescente em canais radiculares curvos que tinham sido obturados com cimento Endosequence BC/Cpoint ou com cimento AH/ guta-percha, depois do retratamento utilizando instrumentos rotatórios ou reciprocantes. Métodos: Sessenta canais mesiovestibulares de molares superiores foram instrumentados até MTwo #35.04. As amostras foram randomicamente alocadas em quatro grupos (n=15): os canais do G1 e G2 foram obturados com AH/guta-percha, e os canais do G3 e G4 foram obturados com BC/Cpoint. O material obturador foi removido usando instrumentos rotatórios ou reciprocantes ­ G1 e G3: R25 Reciproc + reinstrumentação com R40; e G2 e G4: Sistema ProTaper Universal Retratamento + reinstrumentação com MTwo 40.06. Micro-CTs foram usadas para medir a quantidade de material obturador remanescente (mm3 ) para o canal inteiro e para cada terço, em dois momentos: 1) após a remoção do material obturador; e 2) após a reinstrumentação. Resultados: Após a remoção do material obturador, BC/CPoint permaneceu mais dentro do canal do que AH/guta-percha quando o canal inteiro (29,92% x 19,25%, p=0,0290) e o terço apical foram analisados. Após a reinstrumentação, BC/CPoint permaneceu mais do que AH/guta-percha somente no terço apical. Protocolos de tratamento com instrumentos rotatórios ou reciprocantes removeram material obturador sem diferença para AH/guta-percha (G1 e G2: p> 0,05) e BC/CPoint (G3 e G4: p> 0,05). Conclusões: BC/Cpoint é mais difícil de ser removido de canais radiculares curvos do que AH/guta-percha. Instrumentos rotatórios e reciprocantes têm habilidade similar na remoção de material obturador (AU).

Objective: This study used micro-CT to evaluate the amount of remaining filling material in curved root canals obturated with Endosequence BC Sealer/Cpoint or AH/gutta-percha after a rotary or reciprocating retreatment. Methods: Sixty mesiobuccal canals of maxillary molars were instrumented up to MTwo #35.04. Samples were randomly assigned to four groups (n=15): canals from G1 and G2 were filled with AH/gutta-percha, and canals from G3 and G4 were filled with BC/Cpoint. Filling material was removed using rotary or reciprocating instruments: G1 and G3: R25 Reciproc + re-shaping with R40; and G2 and G4: ProTaper Universal Retreatment system + re-shaping with MTwo 40.06. Micro-CT was used to measure the remaining amount of filling material (mm3 ), for the whole canal, and for each third, in two moments: 1) after filling removal and 2) after canal re-shaping. Results: After filling removal, BC/CPoint remained more into the canal than AH/Gutta-percha when the whole canal (29.92% x 19.25%, p = 0.0290) and the apical third were analyzed. After re-shaping, BC/CPoint remained more than AH/Gutta-percha only in the apical third. Rotary or reciprocating retreatment protocols removed filling material without difference for AH/gutta-percha (G1 and G2: p > 0.05) and BC/CPoint (G3 and G4: p > 0.05). Conclusion: BC/Cpoint is more difficult to be removed from curved root canals than AH/gutta-percha. Reciprocating and rotary instruments have similar ability to remove filling material (AU).

Reimplante intencional: que procedimento é esse que pode salvar dentes? Dois relatos de caso em longo prazo / Intentional replantation: What kind of approach is this that can save teeth? Two long term case reports

Introdução: A manutenção da dentição natural é preferível na maioria dos casos. Muito embora hoje em dia se possa contar com os implantes dentários, em casos com prognóstico menos limitado a preservação dos dentes ainda é mais aconselhável que os implantes. A Endodontia, e todas as suas possibilidades terapêuticas existentes, intenta e faz o papel de especialidade que tem como princípio prevenir ou eliminar a periodontite apical, dando condições de reparo e saúde ao periodonto apical e tecido ósseo. Com o advento tecnológico dos últimos anos, os tratamentos de canal se tornaram muito mais previsíveis e isso se reflete no aumento dos índices de sucesso, tanto de tratamentos primários quanto de retratamentos. Contudo, existem casos que falham, mas esses casos não são o fim da linha para o dente. Entre as manobras existentes para se reintervir em dentes que tiveram um tratamento que fracassou, são possíveis a microcirurgia endodôntica apical ou o reimplante intencional. Método: A manobra de reimplante intencional consiste de várias etapas cirúrgicas que vão desde a extração do elemento dental até a reposição de volta ao seu alvéolo. Neste artigo foram descritos dois casos clínicos limítrofes que foram tratados por meio desse procedimento. Resultados: Os casos apresentaram resultados excelentes, como remissão das lesões apicais, reparo ósseo e permanência dos elementos em boca, com acompanhamento de longo prazo (2 e 11 anos). Conclusões: Com altos índices de sucesso já relatados na literatura, essa modalidade de tratamento precisa ser mais explorada e divulgada no Brasil, principalmente entre alunos de pós-graduação e especialistas em Endodontia, pois comprovadamente pode evitar a indicação desnecessária de implantes dentais (AU).

Introduction: The maintenance of natural dentition is preferable in most of cases. However, nowadays it is possible to use dental implants in cases where prognosis is very limited. Endodontics and all of its therapeutic modalities play an important role, which has, in principle, to prevent or eliminate apical periodontitis providing better conditions for wound healing of periapical and bone tissues. In the past few years, with technological advances, root canal treatment became more predictable and this can be seen reflected in the increase of success rates of primary treatment as well as non-surgical retreatment. Nevertheless, some cases can failure but, it is not the end for the tooth, once some therapeutic approaches are possible, like apical microsurgery or intentional replantation. Method: Intentional replantation is an approach in which some surgical steps are done, since the dental extraction until its repositioning back to the socket. In this article two bordering cases were described. Results: 2 and 11 years follow-up confirm the favorable results of this technique. Both cases with no apical lesion, bone healing and dental elements developing their natural functions. Conclusions: The high successful rates described in the literature give to this treatment approach an important face, and that should be more explored and disclosed in Brazil, specially between specialists and post-graduation students, once can avoid unnecessary dental implants (AU).

Asociación de factores de riesgo independientes con fracaso posextubación en pacientes desconectados de la ventilación mecánica / Association of independent risk factors with post-extubation failure in patients undergoing mechanical ventilation weaning

Resumen Introducción: Aun con adecuado protocolo de desconexión de la ventilación mecánica (DVM), el procedimiento falla en 15 a 30 % de los casos. Objetivo: Evaluar la asociación entre factores de riesgo independientes y fracaso posextubación en pacientes con DVM en una unidad de cuidados intensivos. Método: Estudio de cohorte, longitudinal, prospectivo, analítico, que incluyó pacientes sometidos a ventilación mecánica por más de 24 horas y que fueron extubados. Se obtuvieron reportes preextubación de hemoglobina, albúmina, fósforo, índice cintura-cadera y puntuación SOFA. Se definió como fracaso de extubación al reinicio de la ventilación mecánica en 48 horas o menos. Resultados: Se extubaron 123 pacientes, 74 hombres (60 %); la edad promedio fue de 50 ± 18 años. Ocurrió fracaso de extubación en 37 (30 %). Como factores de riesgo independentes se asoció hipoalbuminemia en 29 (23.8 %, RR = 1.43, IC 95 % = 1.11-1.85) e hipofosfatemia en 18 (14.6 %, RR = 2.98, IC 95 % = 1.66-5.35); se observaron dos o más factores de riesgo independientes en 22.7 % (RR = 1.51, IC 95 % = 1.14-2.00). Conclusiones: Identificar los factores de riesgo independentes antes de la DVM puede ayudar a reducir el fracaso de la extubación y la morbimortalidad asociada.

Abstract Introduction: Even with an adequate mechanical ventilation weaning (MVW) protocol, the procedure fails in 15 to 30 % of cases. Objective: To assess the association between independent risk factors (IRFs) and post-extubation failure in patients undergoing MVW in an intensive care unit. Method: Longitudinal, prospective, analytical cohort study in patients on mechanical ventilation for more than 24 hours and who were extubated. Pre-extubation reports of hemoglobin, albumin, phosphorus, waist-hip ratio and SOFA score were obtained. Extubation failure was defined as resumption of mechanical ventilation within 48 hours or less. Results: 123 patients were extubated, out of whom 74 were males (60 %); average age was 50 ± 18 years. Extubation failure occurred in 37 (30 %). Hypoalbuminemia was associated as an independent risk factor in 29 (23.8 %, RR = 1.43, 95 % CI = 1.11-1.85) and hypophosphatemia was in 18 (14.6 %, RR = 2.98, 95 % CI = 1.66-5.35); two or more IRFs were observed in 22.7 % (RR = 1.51, 95 % CI = 1.14-2.00). Conclusions: Identifying independent risk factors prior to MVW can help reduce the risk of extubation failure and associated morbidity and mortality.

Tratamiento de la periimplantitis. Explantación atraumática y nuevo tratamiento con implantes. Reversibilidad de la oseointegración / Treatment of peri-implantitis. Atraumatic explantation and new treatment with implants. Reversibility of osseointegration

La periimplantitis se define como la patología inflamatoria e irreversible que afecta al hueso periimplantario y le hace perder soporte y función al implante según la definición del European Workshop on Periodontology (EWOP). La prevalencia estimada de la periimplantitis es de 28 a 77%. Los diferentes protocolos de abordaje de la periimplantitis nos ofrecen diversas posibilidades: destoxificación de la superficie y regeneración, limpieza mecánica y resección del tejido inflamado, extracción del implante, entre otros. El principal problema de los tratamientos regenerativos es limpiar y desintoxicar correctamente la superficie del implante expuesto, ya que al tratarse de superficies generalmente muy rugosas, las bacterias del medio bucal las colonizan con mucha facilidad y es prácticamente imposible eliminar por completo el biofilm. El protocolo de tratamiento para la periimplantitis se basa en un algoritmo de tratamiento, en el que se retiran los implantes gravemente afectados por periimplantitis de forma atraumática, lo cual garantiza la conservación del lecho al 100% al no retirarse volumen óseo, y cuándo deben utilizarse las trefinas, pues las que se utilizan en el protocolo únicamente rompen la unión ósea de los primeros milímetros sin retirarlo. En el siguiente caso clínico mostramos el retratamiento de un caso de periimplantitis en el que se ha realizado una nueva rehabilitación implantosoportada (AU)

Periimplantitis is defined as the inflammatory and irreversible pathology that affects the peri-implantary bone and causes it to lose support and function to the implant as defined by the European Workshop on Periodontology (EWOP). The estimated prevalence of periimplantitis figures ranging from 28 to 77%. The different protocols for approaching periimplantitis offer different possibilities: detoxification of the surface and re-generation, mechanical cleaning and resection of inflamed tissue and extraction of the implant mainly. The main problem with regenerative treatments is to correctly clean and detoxify the surface of the exposed implant, since as these are generally highly rough surfaces, bacteria in the oral environment colonise them very easily and it is practically impossible to completely eliminate the biofilm. This treatment algorithm, in which implants severely affected by periimplantitis are removed atraumatically, guarantees the conservation of the bed at 100% since no bone volume is removed and trephines must be used, since those used in the protocol only break the bone union of the first few millimetres, without removing it. In the following clinical case, we show the re-treatment of a case of peri-implantitis where a new implant-supported rehabilitation has been performed (AU)

Atención dental del paciente con enfermedad de Alzheimer: informe de caso / Dental care of patient with Alzheimer's disease: case report

Objetivo: Informar la experiencia de un retratamiento de endodoncia efectuado a una paciente con enfermedad de Alzheimer. Caso clínico: Una paciente de 71 años de edad acudió al servicio para un retratamiento endodóntico en canino inferior derecho realizado previamente en otra institución. Durante los procedimientos se registraron dificultades relacionadas con la negativa del cuidador a permanecer en la consulta, episodios de confusión y movimientos involuntarios, por lo cual se resolvió aplicar la técnica decir-mostrar-hacer para el manejo de la conducta, además de un abrebocas metálico y un colimador para la toma de rayos X. Gracias a la cooperación de la paciente, el tratamiento se llevó a cabo con éxito. Conclusiones: Es importante priorizar la atención dental en etapas tempranas de la enfermedad, cuando la disfunción cognitiva aún permite la cooperación y el riesgo de broncoaspiración todavía es bajo. Así mismo, se recomienda promover que el cuidador permanezca durante las sesiones de rehabilitación. El odontólogo debe conocer los fundamentos fisiológicos y conductuales en relación con esta alteración neurológica, a fin de poder adecuar la atención dental a la individualidad de estos pacientes (AU)

Aim: To present a case report about the experience during a re root canal treatment on a patient with Alzheimer's disease. Clinical case: A 71-year-old female patient, attended for endodontic re treatment of her lower right canine, previously root filled elsewhere. Difficulties are reported during the procedures due to the carer's resistance to staying in the dental office during the treatment, episodes of confusion and uncontrolled movements of the patient, opting for the use of the tell-show-do technique for behavior management, metallic mouth opener, and collimator for X-ray taking. The treatment was carried out successfully, and the cooperation of the patient was also achieved. Conclusions: It is important to prioritise dental treatment during the early stages of the disease, when cognitive dysfunction still allows cooperation and there is a low risk of bronchoaspiration. Likewise, it is recommended to encourage the carers to remain in the dental office during treatment. The dentist must know the physiological and behavioral changes that arise as a result of this neurological disorder, to provide dental treatment to these patients (AU)