¿Cómo Intervenir el Proceso de Caries en Personas Mayores? Adaptación del Consenso de ORCA/EFCD/DGZ

Los cambios demográficos y epidemiológicos actuales determinarán un aumento en la prevalencia e incidencia de caries, específicamente lesiones de caries radicular (RCLs, por sus siglas en inglés) en personas mayores, por lo que la necesidad de tratamiento de mayor cobertura y efectividad será también cada vez mayor. Este artículo resume en español la evidencia actual disponible acerca de las recomendaciones clínicas para las intervenciones preventivas, no invasivas, micro o mínimamente invasivas e invasivas para el manejo de la caries dental en personas mayores, con especial énfasis en RCLs. La presente publicación se basa en un taller de consenso, seguido de un proceso de consenso e-Delphi, realizado por un panel de expertos nominados por la Organización Europea para la Investigación en Caries (ORCA), la Federación Europea de Odontología Conservadora (EFCD) y la Federación Alemana de Odontología Conservadora (DGZ). El propósito de este artículo es presentar las principales conclusiones alcanzadas en el consenso de ORCA/EFCD/DGZ para permitir una mejor difusión del conocimiento y la aplicación de estos conceptos en la práctica clínica, orientando la correcta toma de decisiones en el manejo de la enfermedad y RCLs en las personas mayores.

Current demographic and epidemiological changes will condition increased caries prevalence and incidence, specifically root caries lesions (RCLs) in the elderly. There will be a need, therefore, for therapeutic approaches with greater coverage and effectiveness. This article summarizes, in Spanish, the current available evidence leading to clinical recommendations for preventive, non-invasive, micro or minimally invasive and invasive interventions for the management of dental caries in older people, with special emphasis on RCLs. This publication is based on a consensus workshop, followed by an e-Delphi consensus process, conducted by a panel of experts nominated by the European Organization for Caries Research (ORCA), the European Federation of Conservative Dentistry (EFCD) and the German Federation of Conservative Dentistry (DGZ). The purpose of this article is to present the main conclusions reached in the ORCA/EFCD/DGZ consensus to allow a better dissemination of knowledge and the application of these concepts in clinical practice, guiding the correct decision-making for the disease management and the RCLs in the elderly.

Terapias no Invasivas en base a fluoruros de alta concentración para lesiones de caries radicular

La mayor expectativa de vida de la población mundial ha llevado a una mayor conservación dentaria y como consecuencia, a una mayor prevalencia de caries radicular en la población mayor. La información epidemiológica ha mostrado que el enfoque invasivo de la odontología restauradora no ha sido capaz de dar una solución a esta problemática de salud pública. El enfoque de la Minimal Intervention Dentistry (MID), a través de las terapias no invasivas (TNIs) en base a fluoruros de alta concentración, podrían ser la clave para abordar esta problemática debido a su enfoque conservador, centrado en el paciente y a través del curso de vida. Este artículo pretende mostrar la evidencia existente acerca de las TNIs en base a fluoruros de alta concentración más utilizadas para lesiones de caries radicular (RCLs), a saber, los dentífricos de 5.000 ppm, barnices de flúor y fluoruro diamino de plata. La evidencia científica demuestra que estas TNIs son una alternativa terapéutica en población mayor a pesar de la aun limitada evidencia científica existente para este grupo etario. Por lo tanto, se requieren mayores estudios en población mayor que sustenten estas intervenciones clínicas, principalmente en aquella población con compromiso funcional y/o cognitivo.

The longer life expectancy of the world population has led to a greater dental conservation and, as a consequence, to a higher prevalence of root caries in the elderly population. Epidemiological data have shown that the invasive approach of restorative dentistry has not been able to provide a solution to this public health problem. The Minimal Intervention Dentistry (MID) approach, through non-invasive therapies (NIT) based on high-concentration fluorides, could be the key to address this problem due to its conservative, patient-centered and life-course approach. This article aims to show the existing evidence about the most commonly used high-concentration fluoride-based NITTs for root caries lesions (RCLs), namely 5,000 ppm dentifrices, fluoride varnishes and silver diamine fluoride. The scientific evidence shows that these NITs are a therapeutic alternative in the elderly population despite the still limited scientific evidence for this age group. Therefore, further studies are required in the elderly population to support these clinical interventions, mainly in the population with functional and/or cognitive compromise.

Impacto de las técnicas de mínima intervención en el índice de masa corporal de pre escolares con caries de la infancia temprana, seguimiento 1 año / Impact of minimal intervention techniques on the body mass index of preschoolers with early childhood caries, 1-year follow-up

RESUMEN Objetivo: Determinar el impacto de las Técnicas de Mínima Intervención (TMI) en el índice de masa corporal (IMC) de pre-escolares con caries de la primera infancia (CPI). Material y Métodos: Estudio de intervención, relacional y longitudinal. De una población de 100 pre escolares de ambos sexos y de 3 a 5 años se obtuvo una muestra aleatoria de 31, que cumplieron los criterios de inclusión. Se registró las medidas antropométricas: talla-peso e IMC al inicio, 6 y 12 meses. En el examen bucal de tejidos blandos se observó cambios de color y gingivitis; en los tejidos duros alteraciones de estructura, cronología, secuencia de erupción y se aplicó el índice ceo-d; las evaluaciones clínicas fueron al inicio y a los 12 meses. Se aplicaron las TMI preventivas: flúor en barniz, microinvasivas: sellantes ionoméricos y mínimamente invasivas: Técnica de Restauración Atraumática (TRA). Resultados: Las variaciones globales e individuales del IMC al inicio y 12 meses después de aplicar las TMI fueron altamente significativas (p<0,001). En la evaluación final los hallazgos clínicos evidencian cambios positivos y significativos del color de mucosas y grados de gingivitis. El 98% de pre-escolares presentaron CPI e índice ceo-d en promedio 6,5% al inicio y 1,7% después del tratamiento, hipomineralización 45,2%, retraso de erupción 25,8%, alteración en la secuencia y cronología de erupción 29%. Conclusiones: El aumento progresivo global e individual del IMC se relaciona directamente con la aplicación de las TMI, efectivas para recuperar la salud bucal en pre-escolares con CPI a través del tiempo.

ABSTRACT Objective: To determine the impact of Minimal Intervention Techniques (MIT) on the body mass index (BMI) of preschool children with early childhood caries (CIT). Material and Methods : Intervention, relational and longitudinal study. A random sample of 31 was obtained from a population of 100 pre-school children of both sexes and ages 3 to 5 who met the inclusion criteria. Anthropometric measurements were recorded: height- weight and BMI at the beginning, 6 and 12 months. The soft tissue oral examination revealed color changes and gingivitis; in hard tissues alterations of structure, chronology, sequence of eruption and the ceo-d index was applied; clinical evaluations were at baseline and at 12 months. Preventive MITs were applied: fluoride in varnish, microinvasive: ionomeric sealants and minimally invasive: Atraumatic Restoration Technique (ART). Results: The global and individual variations of the BMI at the beginning and 12 months after applying the IMR were highly significant (p <0.001). In finally evaluation, the clinical findings show positive and significant changes in mucosal color and degrees of gingivitis. 98% of preschool children presented CIT and ceo-d index on average 6.5% at the beginning and 1.7% after treatment, hypomineralization 45.2%, eruption delay 25.8%, alteration in the sequence and eruption chronology 29%. Conclusions: The progressive global and individual increase of the BMI is directly related to the application of the IMR; effective to regain oral health in preschool children with CIT over time.

¿Cómo Intervenir el Proceso de Caries en Adultos? Adaptación del Consenso de ORCA/EFCD/DGZ / How to Intervene the Caries Process in Adults? Adaptation of the ORCA/EFCD/DGZ Consensus

RESUMEN: El manejo terapéutico de lesiones de caries primarias y secundarias concentra gran parte del quehacer de los dentistas en el mundo. Recientes cambios en la concepción de la enfermedad de caries llevaron a un panel de expertos de la Organización Europea para la Investigación en Caries (ORCA), la Federación Europea de Odontología Conservadora (EFCD) y la Federación Alemana de Odontología Conservadora (DGZ) a analizar la evidencia y consensuar recomendaciones sobre manejo de caries en adultos. Mediante una reunión en Berlín, Alemania en 2019 y con metodología e-Delphi, los expertos analizaron la evidencia y propusieron recomendaciones clínicas. El propósito de este artículo es presentar una adaptación idiomática de las principales recomendaciones, que incluyen terapias no invasivas (higiene, uso de fluoruros y control de dieta), terapias microinvasiva (sellantes e infiltrantes), terapias necesariamente invasivas y la reparación de restauraciones. Todas las recomendaciones se basan en un enfoque mínimamente invasivo, con un adecuado manejo restaurador. Los dentistas de países hispanoparlantes podrán encontrar recomendaciones basadas en evidencia, provenientes de un consenso de expertos a nivel global, que orienten sus decisiones clínicas, apoyándose en los principios de la odontología de mínima intervención.

ABSTRACT: Therapeutic management of primary and secondary caries lesions concentrates much of the work of dentists throughout the world. Recent changes in caries disease conception and therapeutic management led a panel of experts from the European Organisation for Caries Research (ORCA), the European Federation for Conservative Dentistry (EFCD) and the German Federation for Conservative Dentistry (DGZ) to analyze the evidence and reach consensus on recommendations for caries management in adults. Through a meeting held in Berlin, Germany in 2019 and using an e-Delphi methodology, the experts analyzed the evidence and proposed clinical recommendations. The purpose of this article is to present an idiomatic adaptation to Spanish of the main recommendations, which include non-invasive therapies (hygiene, use of fluoride and diet control), microinvasive therapies (sealants and infiltrants), invasive therapies and repair of restorations. All recommendations are based on a minimally invasive dentistry approach, with a technically adequate restorative management. Spanish-speaking dentists may use these consensus recommendations to guide their clinical decisions, based on the most recent evidence and experts opinions, under the principles of minimal intervention dentistry.

Desigualdades en Salud Bucal para Personas Mayores en Tiempos del COVID-19. La Teleodontología y la Odontología de Mínima Intervención como Caminos de Solución / Oral Health Inequalities for the Elderly in Times of COVID-19. Teledentistry and Minimal Intervention Dentistry as Solution Paths

RESUMEN: Si bien la salud bucal de las personas mayores en Chile y el mundo ya era deficiente, es esperable que los estragos en materia sanitaria, producto de la COVID-19, acentúen este deterioro, particularmente en aquellos con limitaciones cognitivas o funcionales, perpetuando la desigualdad de acceso a la atención odontológica y con ello empeorando su condición de salud bucal y su calidad de vida. La emergente Odontogeriatría debe potenciarse y fortalecerse ante esta verdadera catástrofe sanitaria que se espera ocurra durante y post pandemia. Para ello, no se precisan nuevos desarrollos científicos o tecnológicos, sino la implementación de filosofías y aproximaciones ya disponibles, como son la adopción sistemática de la Teleodontología y de la Odontología de Mínima Intervención (MID). La atención domiciliaria también aparece como una estrategia necesaria ante este nuevo escenario. Este artículo analiza y discute la situación de salud bucal de las personas mayores durante estos complejos tiempos que vive Chile y la humanidad. La pandemia por COVID-19 es una oportunidad única de replantear tanto la práctica clínica como la educación en Odontología, introduciendo nuevos paradigmas, dándole un enfoque de curso de vida e implementando medidas destinadas a corregir las grandes desigualdades con que viven las personas mayores.

ABSTRACT: Although oral health of older people in Chile and the world was already poor, it is expected that the COVID-19 pandemic will increase oral deterioration, particularly in those with cognitive or functional limitations, perpetuating access inequality to dental care and worsening the oral condition and quality of life. Emerging geriatric dentistry should be strengthened in the context of this health catastrophe, expected to occur during and after the pandemic. To face this challenge, no new scientific or technological developments are required, but the implementation of already available philosophies and approaches, such as the systematic adoption of Teledentistry and Minimum Intervention Dentistry (MID). Home care also appears as a necessary strategy in this new scenario. This article analyzes and discusses the oral health situation of older people in these complex times experienced by Chile and the humanity. The COVID-19 pandemic is a unique opportunity to rethink both clinical practice and education in Dentistry, introducing new paradigms, giving it a life course approach and implementing measures aimed at correcting the outrageous inequalities for older people.

Reparación de defecto localizado en restauración de amalgama como tratamiento de mínima intervención en cariología / Repair of a localized defect in a restoration with amalgam filling as minimal intervention treatment in cariology

Introducción: La reparación de restauraciones ha sido estudiada desde muy recientemente, pero a pesar de haber demostrado efectividad y mejoras en la terapéutica de la caries dental, aún tiene seguidores y detractores, lo que justifica la necesidad de estudios que sigan avalando tales prácticas. Objetivo: Describir, a través de la presentación de un caso, la reparación de un defecto localizado en una restauración de amalgama como tratamiento de mínima intervención en cariología. Presentación del caso: Paciente femenina de 16 años con antecedentes de salud acude a consulta refiriendo una pequeña fractura de restauración en diente 4.6 desde hace varias semanas. La regularización del defecto en la restauración, la mínima preparación cavitaria, la eliminación del fragmento de la base intermedia, la protección del complejo dentino-pulpar y el llenado de la cavidad resultante, fueron los primeros pasos de una técnica que se cumplimentó luego del pulido final de la interface tejido dentario-restauración y se evolucionó cinco años después. Se evidenció el estado y presencia de la reparación de la restauración realizada, sin fracturas añadidas, microfiltraciones, sintomatologías, desplazamientos ni pérdidas de la continuidad. Conclusiones: La reparación del defecto localizado de amalgama se realizó con el fin de preservar los tejidos dentarios no afectados como lo dicta la mínima intervención en cariología. Cinco años más tarde, la evolución evidencia una práctica que se tradujo en resultados satisfactorios e incremento de la calidad de vida de la paciente(AU)

Introduction: Restoration repair has been studied recently; but, even when it has demonstrated effectiveness and improvements in the therapy of dental caries, it still has followers and detractors that justify the need for studies that continue supporting such practices. Objective: To describe, through a case presentation, the repair of a defect located in a restoration with amalgam filling as minimal intervention treatment in cariology. Case presentation: Sixteen-year-old female patient with health history that went to the clinic reporting a small fracture of a restoration performed in tooth 4.6 several weeks ago. The regularization of the defect in the restoration, minimum cavity preparation, elimination of the fragment of the intermediate base, protection of the dentin-pulp complex, and filling of the resulting cavity were the first steps of a technique that was completed after the final polishing of the dental tissue/restoration interface that was evolved five years later. The status and presence of the restoration repair performed without added fractures, microfiltration, symptomatology, displacement or loss of continuity was evidenced. Conclusions: The repair of the localized defect in a restoration with amalgam filling was performed with the aim of preserving the unaffected dental tissues as dictated by minimal intervention in cariology. Five years later, the patient´s evolution shows a practice that resulted in satisfactory results and an increase in the patient's quality of life(AU)

Winnicott, Deleuze e o declínio da interpretação / Winnicott, Deleuze y el declive de la interpretación / Winnicott, Deleuze, and the decline of interpretation

Seguindo a linha da crítica da interpretação, desenvolvida em seus escritos mais recentes, o autor propõe uma aproximação teórica entre Donald Winnicott e Gilles Deleuze, concedendo especial atenção à perspectiva imanentista que orienta seus pensamentos atendendo necessidades específicas de seus campos de investigação. Aponta ainda a presença, em suas obras, de uma suspeita fundamental no que concerne à conveniência da interpretação de significados inconscientes e à busca da obtenção de insights, comumente tomadas como premissas clínicas raramente questionadas na constituição do pensar clínico do psicanalista.

Siguiendo la línea de la crítica de la interpretación, desarrollada en sus más recientes escritos, el autor propone una aproximación teórica entre Donald Winnicott y Gilles Deleuze, con especial atención a la perspectiva inmanente que guía sus pensamientos sirviendo a las necesidades específicas de sus campos de investigación. El señala también la presencia, en las dos obras, de una sospecha fundamental en cuanto a la conveniencia de la interpretación de los significados inconscientes y la búsqueda de obtención de insights, tomados como supuestos clínicos poco cuestionados en la constitución del pensamiento del psicoanalista.

The author follows the critique of interpretation he developed in his latest writings, in order to propose a theoretical approach between Donald Winnicott and Gilles Deleuze. The author gives a particular attention to the immanent perspective that guides these authors' thoughts and fulfills the specific needs of their research fields. The author points out that there is a fundamental suspicion, in Winnicott's and Deleuze's works, concerning both the convenience of interpretation of unconscious meanings and the pursuit of insights. And, he continues, both are usually taken as clinical assumptions, rarely questioned in the constitution of the psychoanalyst's thinking.

Minimal-Intervention on smoking cessation: a Meta-analysis / 中华流行病学杂志

Objective To systematically evaluate the effectiveness of Minimal Smoking Cessation Intervention Program (MSCIP) and to provide theoretical basis for the feasibility of implementation in China.Methods Systematically,we searched data from studies published between January,2000 and September,2014 on the database that including Cochrane Library,Medline,EMbase,CNKI,Wanfang,Vip,etc.Studies related to MSCIP were designed by random controlled trials.Meta analysis was performed by Revman 5.1.Results Nine studies were included,with the Random-Effect Model Relative Risk as 1.57 (1.01-2.44),which indicated that the probability of being tobacco abstinent had increased by 57％ in the treating group than in the control group.Participants who developed other diseases,being pregnant or the time of receiving intervention messages ≤ 10 minutes,were more likely to quit the program.There were no significant statistically differences noticed between the different subgroups.Conclusion Minimal smoking cessation intervention increased cessation rates,RCTs with a larger sample size are needed to draw the related conclusions.

Intervencion minima en tabaquismo a pacientes internados. Experiencia en un hospital de Mendoza / Minimal intervention in smoking to inpatients. Experience in a hospital in Mendoza

Objetivos: El medico cumple un importante papel en el control del tabaquismo, una manera de objetivarlo es mediante la intervencion m¨ªnima realizada durante la internacionde pacientes fumadores en un Servicio de Clinica Medica. Material y metodo: Se realiza una encuesta en pacientes internados en el Servicio de Clinica Medica del Hospital del Carmen, horas previas al alta hospitalaria, en un periodo de 30 dias, donde se incluyen datos epidemiologicos, anamnesis, consejo antitabaco y derivacion a cesacion. Se realizan comparaciones estadisticas de ¦Õ2. Resultados: De los 173 pacientes encuestados, el 100% habia sido consultado sobre sucondicion de fumador y constaba en la historia clinica, el 19.1% correspondian a fumador actual, el 34.1% a ex fumador y el 46.8% a no fumador. Durante la internacion se realizointervencion minima en el 33% de los fumadores y del total de fumadores fueron derivados a consultorios de cesacion el 18.1%. Estos pacientes refieren haber recibido consejo medico para dejar de fumar en atenciones medicas previas a la internacion en el 57.5%. Conclusiones: Si bien se destaca que en su totalidad los pacientes internados fueron consultados sobre su condici¨®n tabaquica, solo uno de cada tres recibio intervencion minima, y solo el 18% se derivo a consultorios de Cesacion Tabaquica. Debiendo ser mejorados estos aspectos, sobre todo por contar con varios dias de contacto para esta intervencion y la motivacion extra de la descompensacion del paciente que origino la internacion.

Objectives: Physicians fulfill an important role in tobacco control, especially through the minimal intervention performed during the hospitalization of smoker patients in aninternal medicine service. Material and method: a survey was carried out among patients in an internal medicineservice of Del Carmen Hospital a few hours before hospital discharge. The survey included questions on epidemiological and clinical data, anti-tobacco advice and referral to cessation therapy. The survey was carried out in a period of 30 days. ¦Õ2 statisticalcomparisons were performed. Results: Out of 173 surveyed patients, their clinical records showed that 100% had been questioned on the smoking habit, 19.1% were current smokers, 34.1% former smokers and 46.8% non-smokers. During hospitalization a minimal intervention took place in 33%of smokers and of the total of smokers 18.1% were referred to cessation clinics. Among these patients, 57% reported having received medical advice to quit smoking in medical consultations before the hospitalization.

The correct use of the ART approach

Confusion exists amongst dentists and scientists about the correct use of the caries management approach termed atraumatic restorative treatment (ART). Inconsistent use of the original definition of ART and suggested modifications (mART) have led to misunderstanding, misconception and miscommunication in the dental literature over the last decade. The aim of this paper is to contribute to a uniform understanding and use of the term ART. Adherence to its original description is suggested and two major aspects were addressed: the use of hand instruments only and the use of adhesive materials and systems.

The ART approach: clinical aspects reviewed

The success of ART as a caries management approach is supported by more than 20 years of scientific evidence. ART follows the contemporary concepts of modern cariology and restorative dentistry. It challenges treatment concepts such as step-wise excavation and the need for complete removal of affected dentine. The ART approach so far has mainly used high-viscosity glass-ionomer as the sealant and restorative material. Cariostatic and remineralization properties have been ascribed to this material which requires further research to establish its clinical relevance. The adhesion of high-viscosity glass-ionomer to enamel in pits and fissures is apparently strong, as its remnants, blocking the pits and fissures, have been considered a possible reason for the low prevalence of carious lesion development after the glass-ionomer has clinically disappeared from it. Encapsulated high-viscosity glass-ionomers may lead to higher restoration survival results than those of the hand-mixed version and should, therefore, not be neglected when using ART. Similarly, the use of resin-modified glass-ionomer with ART should be researched. The effectiveness of ART when compared to conventional caries management approaches has been shown in numerous studies. Proper case selection is an important factor for long-lasting ART restoration survival. This is based on the caries risk situation of the individual, the size of the cavity opening, the strategic position of the cavitated tooth and the presence of adequate caries control measures. As the operator is one of the main causes for failure of ART restorations, attending a well-conducted ART training course is mandatory for successful implementation of ART.