O odontólogo frente aos cuidados paliativos na oncologia / The dental surgeon facing palliative care in oncology: a literature review / El odontólogo ante los cuidados paliativos en oncología

Cuidados paliativos são um conjunto de procedimentos ofertados ao paciente por uma equipe multidisciplinar com objetivo de garantir bem-estar, autonomia,conforto e alívio de sintomas decorrentes de doença ou tratamento quando a cura é impossibilitada. O câncer representa uma das doenças que possuem chances de evoluir o paciente ao estágio terminal, momento em que cuidados paliativos são indicados e necessários. Dentro da equipe responsável, o cirurgião-dentista atua na prevenção, diagnóstico e tratamento de lesões expressas no sistema estomatognático que se manifestam estimuladas pelo câncer ou pelos tratamentos utilizados. O objetivo desta pesquisa é destacar a função do odontólogo dentro da equipe multidisciplinar paliativista para pacientes oncológicos. Trata-se de uma revisão bibliográfica sistemáticada literatura. Foram feitas buscas nas plataformas Biblioteca Virtual em Saúde (BVS) e Scientific Electronic Library Online (SciELO) e após aplicação dos critérios de inclusão e exclusão foram selecionados 14 artigos. A literatura evidencia que alterações orais estão relacionadas com o curso da neoplasia ou seu tratamento; as lesões mais descritas foram: mucosite, xerostomia, candidíase, cárie, periodontite e osteorradionecrose. Isso faz com que o paciente sofra limitações em realizar atividades básicas, alterando negativamente a sua qualidade de vida. A complexidade da manifestação oral pode interromper o tratamento antineoplásico. As medidas de enfrentamento mais empregadas para a saúde bucal do paciente oncológico são a laserterapia, bochechos com clorexidina 0,12%, instrução de higiene oral, uso de anti-inflamatórios, analgésicos e antifúngicos. A atuação do odontólogo na equipe multidisciplinar oncológica paliativista é indispensável para o controle das manifestações orais.

Palliative care comprises a set of procedures offered by a multidisciplinary team to patients who cannot be cured, aiming to restore and ensure well-being, autonomy, independence, comfort and relief from symptoms resulting from illness or treatments. Cancer commonly leads the patient to the terminal stage, and at this stage palliative care is indicated and necessary. Composing the multidisciplinary team, the dentist works in the prevention, diagnosis and treatment of injuries that arise in the stomatognathic system, which manifest themselves due to cancer or its treatments. The objective of this research was to highlight the work of the dentist in the multidisciplinary team of palliative care for cancer patients. This is a systematic bibliographic review of the literature, with an integrative character. Study searches were performed in the Virtual Health Library (VHL) and Scientific Electronic Library Online (SciELO). After applying the inclusion and exclusion criteria, 14 articles were selected. Results showed that oral alterations are completely related to the development of the neoplasm or its treatment; the most described lesions were: mucositis, xerostomia, candidiasis, osteoradionecrosis, radiation caries and periodontitis. These injuries make the patient suffer limitations to perform basic activities, such as eating or communicating, negatively altering their quality of life. The complexity of the oral manifestation can determine the interruption of the anticancer treatment. The most used coping measures for the oral healthof cancer patients are: low- potency laser therapy, mouthwash with 0.12% chlorhexidine, instructionin oral hygiene and use of anti-inflammatory, analgesic and antifungal drugs. The role of dentists in the multidisciplinary palliative oncology team is essential for the control of oral lesions.

Los cuidados paliativos son un conjunto de procedimientos ofrecidos al paciente por un equipo multidisciplinar con el objetivo de garantizar el bienestar, la autonomía, el confort y el alivio de los síntomas derivados de la enfermedad o del tratamiento cuando la curación es imposible. El cáncer representa una de las enfermedades que tienen posibilidades de evolucionar al paciente hasta la fase terminal, momento en el que los cuidados paliativos son indicados y necesarios. Dentro del equipo responsable, el cirujano dentista actúa en la prevención, diagnóstico y tratamiento de las lesiones expresadas en el sistema estomatognático que se manifiestan estimuladas por el cáncer o por los tratamientos utilizados. El objetivo de esta investigación es destacar la función del odontólogo dentro del equipo paliativo multidisciplinar para pacientes oncológicos. Se trata de una revisión bibliográfica sistemática. Se realizaron búsquedas en las plataformas Virtual Health Library (BVS) y Scientific Electronic Library Online (SciELO) y tras aplicar los criterios de inclusión y exclusión, se seleccionaron 14 artículos. La literatura muestra que las alteraciones orales están relacionadas con el curso del cáncer o su tratamiento; las lesiones más comúnmente descritas fueron: mucositis, xerostomía, candidiasis, caries, periodontitis y osteorradionecrosis. Esto hace que el paciente sufra limitaciones para realizar actividades básicas, alterando negativamente su calidad de vida. La complejidad de la manifestación oral puede interrumpir el tratamiento antineoplásico. Las medidas de afrontamiento más utilizadas para la salud bucodental de los pacientes con cáncer son la terapia láser, los enjuagues bucales con clorhexidina al 0,12%, las instrucciones de higiene bucodental y el uso de fármacos antiinflamatorios, analgésicos y antifúngicos. La actuación del odontólogo en el equipo multidisciplinar de oncología paliativa es fundamental para el control de las manifestaciones orales.

Eficacia y seguridad del equipo de aspiración de vacío extraoral para prevenir la infección por Sars-cov-2 en personal sanitario expuesto durante procedimientos estomatológicos / Efficacy and safety of extraoral vacuum aspiration equipment to prevent Sars-cov-2 infection in healthcare personnel exposed during stomatological procedures

ANTECEDENTES: El presente documento expone la evaluación de la eficacia y seguridad del equipo de aspiración de vacío extraoral en comparación con el eyector de saliva o el aspirador de secreción con flujo de succión no menor a 50 L/min (actualmente disponibles en la institución), para prevenir la infección por SARS-CoV-2 en personal sanitario expuesto durante procedimientos estomatológicos. ASPECTOS GENERALES: La pandemia por la enfermedad por coronavirus (COVID-19) ha tenido un impacto significativo en la atención odontológica (Abdelrahman et al. 2021; Cagetti et al. 2021). En diversos países, la atención odontológica ambulatoria fue interrumpida al inicio de la pandemia, a excepción de la atención de emergencia y urgencia dental (Abdelrahman et al. 2021; Cagetti et al. 2021). Esta interrupción de las atenciones odontológicas se debió a que 14,tc. 1 el cuidado dental implica un contacto cercano con el paciente durante periodos de tiempo "or prolongados, lo que genera preocupación sobre la transmisión del SARS-CoV-2 a través de la generación de aerosoles durante los procedimientos estomatológicos (Meng, Hua, and Bian 2020; Peng et al. 2020). De acuerdo con los Centers for Disease Control and Prevention (CDC), los dispositivos dentales que generan aerosoles y contaminan el aire incluyen al raspador ultrasónico, la pieza de mano dental de alta velocidad, jeringa de aire o agua, pulido y abrasión por aire (Centers for Disease Control and Prevention 2022). Estos procedimientos generan una mezcla de aerosoles y gotitas (miden 0.001 a 50 pm de diámetro) que contienen sangre y saliva con diversos patógenos (T. S. Singh and Mabe 2009), lo que genera un ambiente con alto potencial de transmisión de enfermedades como la COVID-19 (Peng et al. 2020). En base a este aumento del riesgo de transmisión de SARS-CoV-2 en los trabajadores de salud, los responsables de formular políticas y los equipos clínicos han optado por reevaluar y adaptar la atención odontológica en respuesta a los desafíos de la pandemia por COVID-19 (World Health Organization 2020b). METODOLOGÍA: La búsqueda sistemática se realizó en las bases de datos bibliográficas PubMed, The Cochrane Library, Web of Science y LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud). Asimismo, se realizó una búsqueda en las páginas web de grupos o instituciones que realizan revisiones sistemáticas (RS), evaluación de tecnologías sanitarias (ETS) y guías de práctica clínica (GPC), tales como el National Institute for Health and Care Excellence (NICE), la Canadian Agency for Drugs and Technologies in Health (CADTH), el Scottish Medicines Consortium (SMC), la Haute Authorité de Santé (HAS), el Institute for Quality and Efficiency in HealthCare (IQWiG), el Institute for Clinical and Economic Review (ICER) yen la Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA), y en las principales instituciones o sociedades especializadas en odontología: la American Dental Association y la British Dental Association. Adicionalmente, se llevó a cabo una búsqueda manual en el motor de búsqueda Google utilizando los términos: (("extra-oral" OR extraoral) AND (vacuum OR aspirator OR suction) AND (COVID-19 OR SARS-CoV-2)) y (("extra-oral" OR extraoral) AND (vacuum OR aspirator OR suction) AND (virus OR viral)); revisando en las diez primeras páginas de resultados, a fin de poder identificar otras publicaciones de relevancia que pudiesen haber sido omitidas por la estrategia de búsqueda o que no hayan sido publicadas en las bases de datos bibliográficas consideradas. Finalmente, se realizó una búsqueda manual de las referencias de los estudios que ingresaron a la fase de texto completo, así como una búsqueda manual en la plataforma ClinicalTrials.gov para identificar ensayos clínicos aleatorizados (ECA) en curso o que no hayan sido publicados aún. RESULTADOS: GPC: gula de práctica clínica; ETS: evaluación de tecnologías sanitarias; RS: revisión sistemática; ECA: ensayo clínico aleatorizado; EO: estudio observacional; LILACS: Literatura Latinoamericana y del Caribe en Ciencias de la Salud; BRISA: Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas; JDA: Japan Dental Association, NHS: National Health Service. Flujograma adaptado de: Page MJ, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. CONCLUSIONES: El presente dictamen preliminar tuvo por objetivo realizar una evaluación sobre la eficacia y seguridad del equipo de aspiración de vacío extraoral en comparación con el eyector de saliva y el aspirador de secreción con flujo de succión no menor a 50 L/min (actualmente disponibles en la institución), para prevenir la infección por SARS-CoV-2 en personal sanitario expuesto durante procedimientos estomatológicos. Se identificaron una GPC (Hoshi et al.) y cinco documentos de recomendación realizados por Centers for Disease Control and Prevention, World Health Organization, Dental Council of India, Federal Ministry of Health of Nigeria y Government of Canada relevantes para el tema. La GPC emite una recomendación sobre la tecnología de interés; sin embargo, esta recomendación tuvo un muy bajo nivel de evidencia y recomendación débil debido a que se basó en un único estudio de simulación, lo cual no permite extrapolar los resultados a un entorno clínico de la vida real con pacientes o personal de salud. Ninguno de los documentos de recomendación incluidos emite recomendaciones sobre la intervención de interés (equipo de aspiración de vacío extraoral), sino que hacen referencia a los dispositivos evacuadores de alto volumen que son de uso intraoral, diferentes a lo solicitado. Asimismo, recomiendan otras medidas que se deben tomar en cuenta para mitigar la transmisión de enfermedades durante procedimientos generadores de aerosoles, donde destacan el uso de diques dentales, uso de equipo de protección personal adecuado, odontología a cuatro manos, y enjuagues bucales con clorhexidina. En el documento del MINSA, destacan una serie de disposiciones que deben instaurarse al momento de realizar una atención odontológica. Dentro de estas disposiciones destacan las medidas que debe utilizar el personal de salud dental antes, durante y después de la atención (principalmente, el uso del equipo de protección personal), en los establecimientos odontológicos (como una ventilación adecuada) y el esquema de vacunación completo del personal de salud. Las acciones combinadas tendrían un impacto positivo en la prevención de la infección por SARS-CoV-2. Por lo expuesto, el !ETS' no aprueba el uso del equipo de aspiración de vacío extraoral para prevenir la infección por SARS-CoV-2 en personal sanitario expuesto durante procedimientos estomatológicos.

Respiratory outcomes with the use of a lower custom fit genioglossal-effecting oral appliance.

OBJECTIVE: Sleep apnea research cites that an oral appliance, which places the mandible in a more forward position and the genioglossus (tongue muscle) on the floor of the mouth, improves aspects of the pharyngeal opening. Exercise science research has cited improvements in airway dynamics and physiological variables with oral appliance use during exercise. Thus, the purpose of this study was to design an oral appliance that would act on the genioglossus and determine if there were effects on respiratory parameters while exercising. MATERIALS AND METHODS: Seventeen healthy subjects ages 18-43 participated in this study. Prior to the exercise protocol, the order of the oral applicance (OA) or no oral appliance (no OA) condition was randomly assigned to subjects, with subjects completing both conditions. Respiratory parameters (respiratory rate, ventilation, oxygen, and carbon dioxide) were measured between conditions while subjects ran for 10 min at steady state. RESULTS: The results demonstrated that both respiratory rate (25.97 BPM, OA and 28.35 BPM, no OA) and ventilation (47.66 l/min, OA and 50.34 l/min, No OA) were significantly lowered (p < .01) in the OA condition. There were no differences in carbon dioxide (1.89 l/min, no OA and 1.88 l/min, OA) or oxygen outcomes (2.17 l/min, no OA and 2.17 l/min OA). DISCUSSION: The outcomes from this study suggest that the design of the oral appliance elicits an effect on the genioglossus, thereby resulting in lowered respiratory rate and ventilation with no negative effects on oxygen uptake during exercise.

[Application of Nd:YAG laser in stomatology].

Developments in science and technology include the use of laser as an auxiliary device in treating oral diseases. Nd:YAG laser is convenient and safe to use. Nd:YAG laser irradiation leaves no scabby area on the wound surface, causes a mild reaction postoperation, and promotes high comfort. Therefore, this treatment has attracted increasing attention in the clinical setting. This review enumerates the applications of water-cooled pulsed Nd:YAG laser in hard and soft tissues in oral medicine. Nd:YAG laser in hard tissues can be applied in cavity preparation, acid etching, root canal preparation and sterilization, and dentin desensitization therapy. Meanwhile, the applications of this laser in soft tissues include adjunctive therapy in basic periodontitis treatment, gingival aesthetic treatment, and resection. This review suggests the importance of Nd:YAG laser as an auxiliary device in the clinical diagnosis and treatment of oral diseases.

Validation of the National Institutes of Health (NIH) scale for oral chronic graft-versus-host disease (cGVHD).

The aim of this study was to validate the 2005-2006 National Institutes of Health (NIH) scale for patient's self-reporting and clinical manifestations of oral chronic graft-versus-host disease (cGVHD). Numerical parameters of the NIH scale were analyzed for their construct validity (correlation of the NIH scale with numerical rating scale [NRS] for pain) and internal consistency reliability (correlation between different parameters of the same scale). Categoric parameters were analyzed by comparison between severity subgroups defined by the oral manifestation (lichenoid/erythema/ulceration). Analysis included data of 75 evaluations. The total NIH score and the NRS for pain were found to be moderately correlated (r=0.449). Cronbach's alpha reliability coefficient was .718. Strong correlations were found between the total NIH score and both erythema and ulceration scores (r=0.746 and r=0.926, respectively). The difference between the 2 "severe" subgroups (ie, lichenoid and erythema/ulceration) was significant (P=.025). The difference between the moderate-erythema/ulceration subgroup and the severe-lichenoid subgroup was nonsignificant (total NIH score and NRS for pain: P=.276 and .291, respectively). The correlation between the total NIH score and the NRS for pain is only moderate. The internal consistency reliability analysis yielded good reliability, especially for erythema and ulceration. Analysis of categoric parameters suggests that the NIH scale disproportionately differentiates between moderate-erythema/ulceration and severe-lichenoid cGVHD.

Oral chronic graft-versus-host disease scoring using the NIH consensus criteria.

The National Institutes of Health (NIH) Oral chronic Graft-versus-Host Disease (cGVHD) Activity Assessment Instrument is intended to be simple to use and to provide a reproducible objective measure of disease activity over time. The objective of this study was to assess inter- and intraobserver variability in the component and composite scores in patients evaluated with oral cGVHD. Twenty-four clinicians (bone marrow transplant [BMT] oncologists: BMTE, n = 16; BMT midlevel providers: BMT MLP; n = 4; and oral medicine experts [OME], n = 4), from 6 major transplant centers scored high-quality intraoral photographs of 12 patients. The same photographs were evaluated 1 week later by the same evaluators. An intraclass correlation coefficient (ICC) was used to calculate intrarater reliability and interrater agreement was analyzed using a weighted kappa statistic: 0 or=0.90) and highest for ulcers (0.97, 0.85, 0.94). Although 75% of OME were comfortable with their abilities to score the cases, approximately 50% of BMTE and BMT MLP were uncomfortable. The majority felt that their evaluations were accurate; however, 84% agreed that formal training is required. Interrater variability of the oral cGVHD instrument is unacceptable for the purposes of clinical trials. Greater concordance among OME, high intrarater reliability, and participant feedback suggests that formal training may significantly decrease variability. Parallel investigations must be completed using the other organ specific instruments prior to any revision and widespread prospective utilization of these tools as research endpoints.

Diagnostic methods for detection of signs and symptoms of temporomandibular disorders. Part II.

Temporomandibular disorders (TMD) is a term which includes numerous clinical symptoms that affect the teeth and their supportive apparatus, masticatory muscles and jaw joints. They are frequently the cause of orofacial painful conditions. Etiology of dysfunction is complex and the role and importance of certain etiological factors are inadequately defined. This study includes a review of the literature and presentation of a diagnostic protocol for the detection of signs and symptoms of TMD. Optoelectronic pantography enables the application of relatively uncomplicated methods for more precise and simpler diagnosis of the above disorder, at the same time recording the results in its software and storing them, which can be extremely important during the choice of therapeutic procedure and the control of therapy efficacy.

The effect of direct and alternating electrical currents on the vessel walls of the tooth pulp -- TEM studies.

Devices which operate on the basis of electrical charges are increasingly being used in stomatology, such as in cariology for the detection of invisible caries lesions or for the measurement of canal lengths during patient treatment. The majority of these devices now emit a current of alternating frequency. The aim of the work was to explain how the electrical devices of labile frequency commonly used in stomatology influence the vessels of the tooth pulp. Teeth extracted for orthodontic reasons were investigated with the use of a transmission electron microscope. The teeth were treated with current emitted by a specially constructed device. The control group comprised 4 teeth. No changes were found in the electron microscopic studies in the slides of the teeth treated with low charges of current. However, in the specimen treated with current charges of 9600 microC or more flattened endotheliocytes were found together with exudation in the vessel lumen. Cases are referred to in which the duration of the work was 2 or 3 times longer than normal and in which a current of constant intensity was emitted uninterruptedly.

Handy measurement for tongue motion and coordination with laryngeal elevation at swallowing.

At the oral stage of swallowing, the tongue plays a major role and proper tongue performance is necessary to form the bolus and transfer it to the pharynx. For the present study we built a prototype device for safe and handy objective estimation of tongue motion and coordination with laryngeal elevation at swallowing. The device records tongue pressure by means of two strain gauge pressure transducers aligned 20 mm apart on a brass strap placed along the palatal midline. Laryngeal vibration is recorded with piezo-electric acceleration transducers. Time differences between pressure onset at the anterior and posterior transducers and the first spike from laryngeal vibration are measured. Ten healthy subjects were asked five times to swallow 5 mL of water. Pressure onset at the anterior transducer preceded posterior pressure by 294 +/- 164 ms. Given the distance between the transducers, the tongue contracted (squeezed) at a speed of 93 +/- 60 mm s(-1). Laryngeal vibration occurred 671 +/- 175 ms after the onset of anterior pressure. There was considerable variation in these parameters between subjects. Though the data is limited, the device successfully and easily revealed certain aspects of tongue motion and coordination with laryngeal elevation.

[Fundamental study on the development of a measuring device using an accelerometer].

It is important to clarify stomatognathic functions. To diagnose them, some measuring devices, such as MKG and the Gnatho-hexagraph, were developed. Such equipment, however, is not widely diffused, due to cost. The purpose of this fundamental study was to obtain information on position using an accelerometer. This system consists of a micro dual-axis accelerometer and a peripheral interface controller. Two-dimensional acceleration, velocity, and movement can be calculated by a computer. We examined the accuracy of this system using a laser measuring device. The result was as follows: The accuracy of the system was 0.03 (p-p values) using acceleration of gravity and a frequency of 72.5 Hz. In the present study, mandibular movements during chewing raisins were analyzed using this system. The new system demonstrated its value for analyzing mandibular movements.

High frequency (20 MHz) ultrasonic devices: advantages and applications.

OBJECTIVE: This paper investigates the problems, advantages and potential applications of 20 MHz ultrasonic devices. METHOD: Aqueous gel and a thin appropriate membrane to enclose the front tip were used with 20 MHz probes without obvious decrease in resolution and sensitivity compared to the results obtained without a membrane and this considerably facilitates their routine use. RESULTS: Many applications with linear scanning were evaluated in dermatology, ophthalmology (investigations of the anterior chamber of the eye, checking of corneal grafts), stomatology (detection and evaluation of periodontal disease) and in the field of measurement of very low velocities in small vessels by means of a duplex probe comprising two 20 MHz transducers: an imaging transducer and an inclined blood flow measurement transducer. Velocity profiles (velocities less than 0.50 mm/s) were measured in 100-300 microm diameter vessels using a cross-correlation method. CONCLUSION: The use of 20 MHz frequency limits resolution but we have shown that this frequency allows the development of easy to handle probes.