Successful retreatment of a maxillary central incisor with a wide-open apex using MTA to fill the entire canal: 24-year follow-up.

Managing teeth with open apices can be a challenging scenario for clinicians. This case report describes the 24-year follow-up of a maxillary central incisor that failed to develop after a traumatic injury resulting in a wide-open apex. A 10-year-old girl presented complaining of discomfort in her upper teeth. Tooth #9 had received a traumatic blow several years before and was discoloured with a resin composite restoration on the mesio-incisal edge. The tooth was painful to percussion and palpation. An inadequate root canal filling and incomplete root formation were observed on the initial periapical radiograph. Root canal retreatment was initiated, and the canal filled entirely with mineral trioxide aggregate (MTA) because of the extremely wide canal and open apex. The patient was asymptomatic at the 24-year follow-up with the cone beam computed tomography and periapical radiographs demonstrating the stability of the MTA.

Outcome of Nonsurgical Root Canal Retreatment of Teeth with Persistent Apical Periodontitis Treated with Foraminal Enlargement and 2% Chlorhexidine Gel: A Retrospective Cohort Study.

INTRODUCTION: Nonsurgical root canal retreatment (NS-RCRT) becomes necessary when primary endodontic procedures fail. This study evaluates the efficacy of NS-RCRT using 2% chlorhexidine gel and foraminal enlargement techniques, aiming to assess whether these approaches enhance periapical healing outcomes and success rates compared to traditional NS-RCRT techniques reported in the literature. METHODS: This retrospective cohort study analyzed 120 teeth diagnosed with persistent apical periodontitis, from 80 patients who underwent NS-RCRT between January 2014 and December 2018 at a specialist's private practice. Data were collected following the Preferred Reporting Items for Observational Studies in Endodontics 2023 guidelines. Periapical healing was evaluated using digital periapical radiographs by three calibrated examiners. The outcome of the treatment was analyzed through descriptive statistics and bivariate analyses, including the Chi-Square and Fisher's Exact tests. Treatment outcomes were deemed successful if they showed complete or incomplete repair and unsuccessful if no repair was observed. RESULTS: The average follow-up period was 30 months. Under loose criteria, 92.50% (n = 111) of the teeth were categorized as successful, and 7.5% (n = 9) as unsuccessful. Bivariate analysis indicated that the radiographic restoration of apical transportation was the only factor that significantly influenced the outcome. CONCLUSIONS: NS-RCRT performed in a single visit using the foraminal enlargement technique and 2% chlorhexidine gel demonstrated high success rates and may be an effective alternative to tooth extraction. This method promoted periapical healing and could significantly improve NS-RCRT protocols. Further prospective studies are recommended to corroborate these findings.

CBCT assessment of mandibular molar furcation following root canal retreatment using engine-driven instruments.

This study employed e-Vol DXS cone beam computed tomography (CBCT) software to assess dentin remnants in the furcation area of mesial canals in mandibular molars during root canal retreatment (RCR). Four groups (Reciproc®, ProTaper Next®, Race Evo®, Protaper Gold®) were subjected to RCR, and CBCT images were captured before (T1) and after (T2) treatment. Measurements of remaining dentin thickness at 1 mm and 3 mm below the furcation were scrutinized. Results revealed no significant differences in mean thicknesses of mesiobuccal (MB) and mesiolingual (ML) canals at 1 mm and 3 mm from the furcation pre-treatment (T1). Post-treatment (T2) showed analogous findings, with no significant differences in mean thicknesses. However, disparities were found between MB and ML canals at both distances, both before and after retreatment. In essence, the evaluated instruments exhibited safety in RCR, implying that they are appropriate for use in critical areas of mandibular molars without inducing excessive wear. This study underscores the reliability of these instruments in navigating danger zones during RCR, and contributes valuable insights for dental practitioners who handle complex root canal scenarios in mandibular molars.

Minimally invasive guided endodontic microsurgery with Zekrya bur: A 48-month follow-up case report.

Endodontic microsurgery guided by navigation systems represents a precise and minimally invasive approach for retreatment of apical periodontitis following failed conventional endodontic therapy. Accurate localization and minimal access to the root apex are paramount for successful outcomes and preservation of anatomical structures. Workflow considerations, such as three-dimensional (3D) virtual planning and endodontic guidance represent new crucial aspects for addressing complex cases. This clinical case report presents the successful reintervention of a complex case using a Zekrya bur, operative microscopy, cone beam computed tomography and biocompatible materials. After a 48-month follow-up, complete healing of the treated area was observed. This minimally invasive technique, employing a simple instrument widely available globally, underscores the potential for efficient and predictable outcomes in complex endodontic microsurgical retreatment.

Influence of Initial Root Canal Treatment on Intratubular Penetrability and Bond Strength of Nonsurgical Retreatment: An InVitro Study.

INTRODUCTION: To assess the effect of combinations of two different endodontic sealers used in initial and endodontic retreatment on the bond strength of the secondary obturation and the penetrability of the sealers. METHODS: Forty-eight mandibular premolars were used, receiving standardized endodontic access and biomechanical preparation. Twenty-four teeth received AH Plus sealer (AHP) in primary obturation and the others received Bio-C Sealer (BCS). Retreatment protocol was performed with an R50 instrument. The samples were further subdivided into four groups (n = 12) based on the combination of primary/secondary obturation sealers: AHP/AHP; AHP/BCS; BCS/AHP; and BCS/BCS. Four samples from each subgroup received the addition of fluorophores to the sealer for penetrability analysis using laser scanning confocal fluorescence microscopy. The root portion on the 8 push-out samples was sectioned into 6 slices of 1.0 mm. Bond strength (BS) was assessed using a universal testing machine until displacement of the filling mass. Failure pattern was evaluated under a stereomicroscope (20× magnification). BS data were analyzed using two-way analysis of variance followed by Tukey's test (P < .05), and the association between the failure pattern and BS value was assessed using the chi-square test (P < .05). Penetrability was qualitatively evaluated. RESULTS: The highest BS values were observed in the AHP/AHP (4.54 ± 1.5 MPa) and BCS/AHP (5.00 ± 1.0 MPa) groups (P < .05), with a higher percentage of adhesive failures to the filling material for all groups. Laser scanning confocal fluorescence microscopy images indicated greater penetrability of AHP compared to BCS, both in initial treatment and retreatment. CONCLUSION: AHP sealer exhibited higher BS and greater penetrability compared to BCS sealer.

Outcome of Nonsurgical Root Canal Treatment of Teeth With Large Apical Periodontitis Lesions: A Retrospective Study.

INTRODUCTION: This study reported on the outcome of the nonsurgical root canal treatment/retreatment of teeth with large apical periodontitis lesions. The influence of some variables on the prognosis was also evaluated. METHODS: The study included 199 teeth with large apical periodontitis lesions from 184 patients, treated/retreated by a single operator. Most teeth were managed in a single visit using NaOCl irrigation. Cases were followed up periodically from >1 to 8 years. Treatment/retreatment outcome was evaluated by clinical and radiographic/tomographic criteria and categorized as healed, healing, or diseased. For statistical analysis, data were dichotomized in such a way that healing cases were considered as success in a loose criterion or failure in a rigid one. RESULTS: Clinical/radiographic analyses revealed that 67% of the initial treatment cases were classified as healed, 22.5% as healing, and 11% as diseased. Treatment success rates were 89% (loose) and 67% (rigid). Variables that influenced the treatment outcome included previous abscess and antibiotic use, very large lesions (≥10 mm), and a sinus tract. The median follow-up time for treatment was 31.5 months. As for retreatment cases, 47% were healed, 32% were healing, and 21% were diseased. Retreatment success rates were 79% (loose) and 47% (rigid), in a median follow-up of 32 months. Cases evaluated by cone-beam computed tomography had lower healed rates. CONCLUSIONS: Findings demonstrate that high favorable outcome rates can be achieved by nonsurgical root canal treatment or retreatment of teeth with large apical periodontitis lesions.

Postoperative pain in oncological patients subjected to nonsurgical root canal treatment: a prospective case-control study.

OBJECTIVES: The purpose of this prospective study was to evaluate the incidence and intensity of postoperative pain in oncological patients with infected teeth subjected to nonsurgical root canal treatment or retreatment. METHODS: Teeth with apical periodontitis from healthy control patients and oncological patients (n = 70 per group) were root canal treated/retreated and evaluated for the development of postoperative pain. Patients from the two groups were matched for tooth type, gender, clinical manifestation of apical periodontitis, and intervention type. A visual analogue scale (VSA) was used to evaluate the incidence of postoperative pain at 24 h, 72 h, 7d, and 15d after chemomechanical procedures. Data were statistically analyzed for the incidence and intensity of postoperative pain in the two groups. RESULTS: Preoperative pain occurred in 10% of the individuals and in all these cases pain showed a reduction in intensity or was absent after endodontic intervention at 24-h evaluation. The overall incidence of postoperative pain at 24 h was 14% in oncology patients and 30% in controls (p = 0.03). At 72 h, the respective corresponding figures were 4% and 8.5% (p > 0.05). At 7 and 15 days, all patients were asymptomatic, irrespective of the group. CONCLUSIONS: No significant differences in postoperative pain were found between control and oncological patients. The low incidence of postoperative pain observed in both groups supports the routine use of nonsurgical root canal treatment/retreatment as valid options in oncological patients. CLINICAL RELEVANCE: Oncological patients had no increased risk of postoperative pain in comparison with control patients.

Retratamiento endodóntico no quirúrgico de molar inferior con lesión apical: estrategia terapéutica / Non-surgical endodontic retreatment of a lower molar with an apical lesion: therapeutic strategy

La terapéutica endodóntica se apoya básicamente en dos modelos teóricos o paradigmas: el concepto de "tubo hueco" técnico y quirúrgico esencialmente mecanicista, y el modelo terapéutico para conductos radiculares, que busca la restitución ad integrum de los tejidos apicales y el hueso alveolar que los rodea. La instrumentación debe complementarse con la limpieza por irrigación abundante y la obturación con un biomaterial bioactivo, con características reológicas que permitan su adaptación plástica a las paredes del conducto radicular y module la respuesta de los tejidos hacia la regeneración con aposición de tejido calcificado en el foramen apical (AU)

Endodontic therapy is basically based on two theoretical models or paradigms, which are the concept of the technical and surgical "hollow tube", essentially mechanistic, and the therapeutic model of root canals, which seeks the ad integrum restitution of the apical tissues and bone. alveolar that surrounds them. The instrumentation must be complemented with cleaning by abundant irrigation, and with a bioactive biomaterial, with rheological characteristics that allows its plastic adaptation to the walls of the root canal and modulates the response of the tissues towards regeneration with apposition of calcified tissue in the apical foramen (AU)

Outcomes of repeat conventional transarterial chemoembolization in patients with liver metastases.

INTRODUCTION AND OBJECTIVES: Although unlimited sessions of conventional transarterial chemoembolization (cTACE) may be performed for liver metastases, there is no data indicating when treatment becomes ineffective. This study aimed to determine the optimal number of repeat cTACE sessions for nonresponding patients before abandoning cTACE in patients with liver metastases. MATERIALS AND METHODS: In this retrospective, single-institutional analysis, patients with liver metastases from neuroendocrine tumors (NET), colorectal carcinoma (CRC), and lung cancer who underwent consecutive cTACE sessions from 2001 to 2015 were studied. Quantitative European Association for Study of the Liver (qEASL) criteria were utilized for response assessment. The association between the number of cTACE and 2-year, 5-year, and overall survival was evaluated to estimate the optimal number of cTACE for each survival outcome. RESULTS: Eighty-five patients underwent a total of 186 cTACE sessions for 117 liver metastases, of which 30.7 % responded to the first cTACE. For the target lesions that did not respond to the first, second, and third cTACE sessions, response rates after the second, third, and fourth cTACE sessions were 33.3 %, 23 %, and 25 %, respectively. The fourth cTACE session was the optimal number for 2-year survival (HR 0.40; 95 %CI: 0.16-0.97; p = 0.04), 5-year survival (HR 0.31; 95 %CI: 0.11-0.87; p = 0.02), and overall survival (HR 0.35; 95 %CI: 0.13-0.89; p = 0.02). CONCLUSIONS: Repeat cTACE in the management of liver metastases from NET, CRC, and lung cancer was associated with improved patient survival. We recommend at least four cTACE sessions before switching to another treatment for nonresponding metastatic liver lesions.

Influence of sealer and supplementary approach on filling material removal during endodontic retreatment.

Both root canal sealer-based and supplementary protocols may influence removal of filling material during endodontic retreatment. Mesial root canals of extracted mandibular molars were prepared using HyFlex EDM 25/.08, and filled with a calcium silicate sealer (Bio-C Sealer), or an epoxy resin (AH Plus), using the single cone technique (n = 12). Retreatment was performed using ProDesign Logic (PDL) RT and PDL 35/.05. The specimens were randomly divided into two experimental groups (n = 12), and the sealers were distributed similarly. A supplementary protocol was performed with PDL 50/.01 or XP-endo Finisher. Root canal transportation and volume, in addition to the remaining filling material percentage were evaluated using high-resolution (5 µm voxel size) micro-CT. Statistical analysis was performed using t-tests (α = 0.05). Root canals filled with AH Plus presented high residual filling material (p < 0.05). Both protocols decreased residual volume of filling material in the apical third (p < 0.05). PDL 50/.01 increased the apical root canal volume (p < 0.05). No difference was observed between the systems regarding canal transportation (p > 0.05). In conclusion, AH Plus is more difficult to remove from the apical third than Bio-C Sealer. PDL 50/.01 and XP-endo Finisher enabled greater removal of filling materials in the apical third, in the retreatment of curved root canals, without promoting apical transport.

A critical analysis of the decreasing trends in tuberculosis cure indicators in Brazil, 2001-2022.

OBJECTIVE: To analyze the temporal trend of tuberculosis cure indicators in Brazil. METHODS: An ecological time-series study using administrative data of reported cases of the disease nationwide between 2001 and 2022. We estimated cure indicators for each federative unit (FU) considering individuals with pulmonary tuberculosis, tuberculosis-HIV coinfection, and those in tuberculosis retreatment. We used regression models using joinpoint regression for trend analysis, reporting the annual percentage change and the average annual percentage change. RESULTS: For the three groups analyzed, we observed heterogeneity in the annual percentage change in the Brazilian FUs, with a predominance of significantly decreasing trends in the cure indicator in most FUs, especially at the end of the time series. When considering national indicators, an average annual percentage change of -0.97% (95% CI: -1.23 to -0.74) was identified for the cure of people with pulmonary tuberculosis, of -1.11% (95% CI: -1.42 to -0.85) for the cure of people with tuberculosis-HIV coinfection, and of -1.44% (95% CI: -1.62 to -1.31) for the cure of people in tuberculosis retreatment. CONCLUSIONS: The decreasing trends of cure indicators in Brazil are concerning and underscore a warning to public authorities, as it points to the possible occurrence of other treatment outcomes, such as treatment discontinuity and death. This finding contradicts current public health care policies and requires urgent strategies aiming to promote follow-up of patients during tuberculosis treatment in Brazil.

Effect of the timing of primary endodontic treatment and dosage of radiation therapy on the filling material removal.

This study investigated the effect of the timing of primary endodontic treatment and dosage of radiotherapy on the remaining filling material (RFM) during endodontic reintervention. 60 single-rooted human mandibular premolars were distributed into five groups (n = 12), according to the timing and dosage of radiation (55Gy or 70Gy): NegativeCG-non-irradiated teeth; Endo-pre-RT55/70-obturation before irradiation (55Gy or 70Gy); Endo-post-RT55/70-obturation and reintervention after irradiation (55Gy or 70Gy). Roots were cleaved and analysed under stereomicroscope and Scanning Electron Microscope to quantify (%) the RFM. Experimental groups had a significantly greater amount (p < 0.05) of RFM in the middle and apical thirds than the control group, except for Endo-pre-RT55 in the middle third (p < 0.0001). The apical third had greater amount of RFM (p < 0.05). Radiation therapy, before and after primary endodontic treatment, increased the amount of RFM, regardless of the dose delivered. When necessary, reintervention preferably must be performed before radiation therapy.

Long-term functional outcomes and surgical retreatment after thulium laser enucleation of the prostate: A 10-year follow-up study.

BACKGROUND: To evaluate the 10-year functional outcomes (primary) and frequency and predictors of BPH surgical retreatment (secondary) after ThuLEP. MATERIALS AND METHODS: A single-center retrospective analysis of consecutive patients undergoing ThuLEP between 2010 and 2013 was performed. Inclusion criteria were: age ≥ 40 years, prostate volume (PV) ≥ 80 mL, International Prostate Symptom Score (IPSS)-Total score ≥ 8 points. IPSS-Total score was the primary outcome, and BPH surgical retreatment rate was the secondary outcome. Paired t-test, McNemar test, and Wilcoxon signed-rank test were used to compare variables. Logistic regression analysis was performed to evaluate predictors of surgical retreatment. RESULTS: A total of 410 patients with a mean ±SD age of 63.9 ± 9.7 years and a PV of 115.6 ± 28.6 mL were included. Mean ±SD follow-up was 108.2 ± 29.6 months. IPSS-Total score was significantly improved at 1 year compared to baseline (23.3 ± 4.7 vs. 10.3 ± 3.8; p<0.001). It was similar after 5 years (10.5 ± 3.6 vs. 10.7 ± 5.0; p=0.161), with a significant worsening at 10 years (10.3 ±4.8 vs. 13.8 ±4.5; p=0.042) but remaining statistically and clinically better than baseline (13.8 ±4.5 vs. 22.1 ±4.3; p<0.001). After 10 years, 21 (5.9%) patients had undergone BPH reoperation. Baseline PV (adjusted OR 1.27, 95% CI 1.09-1.41; p<0.001) and time from BPH surgery (adjusted OR 1.32, 95% CI 1.15-1.43; p<0.001) were predictors of BPH surgical retreatment. CONCLUSIONS: ThuLEP is associated with optimal functional outcomes and a low frequency of BPH surgical retreatment in the long-term. Baseline PV and time from surgery were predictors of BPH reoperation.

Geriatric Characterization of Older Persons with Deficient Removable Dental Prostheses / Caracterización Geriátrica de Personas Mayores con Prótesis Dentales Removibles Deficientes

Aging is a gradual and adaptive process that entails a series of changes, leading to reduced functional and physiological capacity. Each elderly person presents heterogeneous health conditions that must be considered by the interdisciplinary team responsible for their functional maintenance and overall health. This descriptive, cross-sectional study was conducted on elderly individuals with deficient removable dental prostheses, treated at the dental prosthetic rehabilitation centre of Hospital Del Salvador, in Santiago de Chile between the years 2021 and 2023. Instruments and indices were used to record and measure muscular conditions, such as the hand grip strength measurements, the Timed Up and Go test, and the calf circumference measurement. Information on educational levels, geriatric syndromes, chronic diseases, and medication consumption was collected. Of the participants, 58.9 % were female, and 41.1 % were male, with a mean age of 84.2 years for males and 80.4 years for females. 20.8 % had access to higher education, and 22.6 % lived alone. 78.5 % had lost all posterior support zones. 81.5 % had visual impairments; 36.3 % had auditory impairments, and 31.5 % had experienced one or more falls in the last 6 months. The mean sum of medications consumed per person was 4.32. The most prevalent morbidities were arterial hypertension (66.4 %) and type II diabetes (32.7 %). Means values for male/ female were: Hand Grip Strength 27.84 Kg/17.99 kg, Timed Up and Go 14.3 sec/14.9sec, BMI 27.16/ 26.44, and calf circumference 35.5 cm /35.2cm, values were within the normal range of values. The data collected is important to consider when treatment planning and implementing actions aimed at maintaining oral and general functionality. These aspects should be addressed from a multidimensional perspective, including risk factors, in both the diagnosis and dental treatments.

Envejecer es un proceso gradual y adaptativo que conlleva cambios, que reducen la capacidad funcional y fisiológica. Cada persona mayor presenta condiciones de salud heterogéneas que deben ser consideradas por el equipo interdisciplinario a cargo de su mantención funcional y estado de salud. Estudio descriptivo, corte transversal, en personas mayores portadoras de prótesis dentales removibles deficientes, del servicio dental de rehabilitación protésica del Hospital Del Salvador de Santiago de Chile, entre los años 2021-2023. Se emplearon instrumentos e índices para realizar registro y medición de condiciones musculares como fuerza de presión manual, prueba Timed Up and Go y medición del perímetro de pantorrilla. Se recolectó información asociada a nivel de escolaridad, síndromes geriátricos, enfermedades crónicas y cantidad de fármacos que consumen. Un 58,9 % eran mujeres, la edad media de hombres fue de 84,2 años y la de mujeres fue de 80,4 años. Un 20,8 % tuvo acceso a educación superior. El 22,6 % vive solo. Un 78,5 % ha perdido todas las zonas de soporte dentario posterior. Un 81.5 % tiene alteraciones visuales; un 36.3 % alteraciones auditivas; un 31.5 % ha tenido 1 o más caídas en los últimos 6 meses. La media de fármacos fue de 4.32 por persona. Las morbilidades más prevalentes fueron hipertensión arterial (66.4 %) y diabetes tipo II (32,7 %). Los valores promedios encontrados para hombres/mujeres en fuerza de prensión manual fueron 27,84 Kg/17,99 kg, Timed Up and Go fueron 14,3 sec / 14,9 sec, IMC 27,16/ 26,44 y perímetro de pantorrilla 35,5 cm / 35,2 cm. Todos los datos clasificaron en el rango de normalidad. Las características observadas son importantes a considerar al momento de planificar tratamientos e implementar medidas orientadas a mantener funcionalidad oral y general. Éstas deben ser abordadas desde una mirada multidimensional, incluyendo los factores de riesgo, tanto en el diagnóstico como su tratamiento odontológico.

Factors influencing the outcome of nonsurgical root canal treatment and retreatment: A retrospective study.

This study assessed the influence of diverse variables on the outcome of nonsurgical root canal treatment/retreatment. In general, 304 teeth from 218 patients were treated/retreated and the outcome evaluated by the periapical index (PAI). Teeth with apical periodontitis lesions that have not completely healed were classified as success or failure based on lenient and rigid criteria, respectively. Findings were evaluated using a logistic regression analysis. The overall success rates were 74% and 82% using the PAI-rigid and lenient success criteria, respectively. Specifically for treatment, the success rates were 73% (rigid) and 82% (lenient), while for retreatment they were 78% (rigid) and 83% (lenient). The treatment outcome was negatively affected by overextension, presence of preoperative lesion, lesion size >10 mm, and higher number of treatment visits (with no intracanal medication). Regarding retreatment, the chance of success was greater for teeth with adequate coronal restorations.

Flatsonic Ultrasonic Tip Optimizes the Removal of Remaining Filling Material in Flattened Root Canals: A Micro-computed Tomographic Analysis.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of the XP-endo Finisher R (XPFR; FKG Dentaire, La Chaux-de-Fonds, Switzerland) or the Flatsonic ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, SP, Brazil) in removing remaining filling material after the retreatment of flattened root canals using micro-computed tomographic imaging. METHODS: Twenty-four flattened distal root canals of mandibular molars with a buccolingual diameter 4 or more times larger than the mesiodistal diameter were prepared with Reciproc Blue (RB) R40 (VDW GmbH, Munich, Germany) and filled using the Tagger hybrid technique. All canals were retreated with RB R40, and apical enlargement was performed with RB R50 (VDW GmbH). The specimens were randomly distributed into 2 groups: XPFR or Flatsonic (n = 12). The percentage of remaining filling material after retreatment and centralization ability was evaluated. Data were submitted to Mann-Whitney, Wilcoxon, and unpaired t tests (α = 5%). RESULTS: Greater capacity to remove remaining filling material in the entire canal and the cervical and middle thirds was observed for the Flatsonic compared with the XPFR (P < .05). However, both supplementary cleaning techniques showed a similar percentage of residual filling material in the apical third (P > .05). No difference was observed in the centralization ability between the techniques (P > .05). CONCLUSIONS: The Flatsonic promotes greater removal of remaining filling material than the XPFR in the retreatment of flattened root canals. However, both supplementary cleaning approaches were similar in the apical third. The XPFR and Flatsonic were able to maintain root canal centralization.

Evaluation of changes in root canal length and accuracy of the electronic apex locator during different stages of endodontic treatment and retreatment.

This study evaluated changes in the root canal length (RCL) and the accuracy of the electronic apex locator (EAL) during the different stages of endodontic treatment and retreatment. Fifty-six mesial root canals of mandibular molars were selected. The actual root canal length (AL) of the canals was obtained by inserting a size 15 hand file up to the apical foramen, under magnification. The electronic lengths were obtained at the "APEX" mark of Root ZX II, using an alginate model. Both measurements were performed at three different stages of the initial root canal treatment-unflared, flared, and concluded-and at two stages of retreatment, after achieving patency and repreparation. Data were statistically analyzed and the significance level established was 5%. All stages produced a significant reduction in the AL (p < 0.05). The greatest variation was observed between the unflared-flared stages (0.2 mm) and between concluded-patency stages (0.09 mm), with no difference between them (p > 0.05). The accuracy of Root ZX II was negatively affected after achieving patency, presenting statistically significant difference compared to the other stages (p < 0.05). A significant reduction in the RCL was observed along the different stages of endodontic treatment and retreatment. The EAL was accurate to measure the root canals in most stages, except after achieving patency for endodontic retreatment. Determining and monitoring the RCL is an essential step towards a favorable prognosis, since it reduced along the different stages evaluated. Root ZX II was not accurate for endodontic retreatment.

Long-term follow-up of repeated corneal cross-linking for progressive keratoconus in young patients / Acompanhamento a longo prazo do retratamento com cross-linking corneano para ceratocone em progressão em pacientes jovens

ABSTRACT Objective: To evaluate the long-term safety and efficacy of repeated corneal cross-linking in eyes of children and adolescents with progressive keratoconus. Methods: This retrospective study included nine eyes of nine consecutive patients with progressive keratoconus who underwent repeated corneal cross-linking 3.9 (range of 1.6 to 5.6) years after a primary one. All patients were followed for a mean period of 9.11 (range of 6 to 11) years after first treatment and 5.44 (range of 4 to 9) years, after corneal cross-linking retreatment. Results: Nine eyes of nine patients (six male) with progressive keratoconus underwent primary corneal cross-linking from 2009 to 2011. Despite the stability achieved with the epi-off corneal cross-linking, keratoconus continued to progress after some time. Mean time to documented evidence of keratoconus progression after primary corneal cross-linking was 3.9 (range of 1.6 to 5.6) years. All eyes were retreated as soon as progression was noted. At the last follow-up visit, 5.44 (range of 4 to 9) years after repeated corneal cross-linking, there was a significant decrease of 2.02 D in mean maximum topographic K-value (p = 0.045) and 1.95D in mean topographic K-value (p = 0.007). Conclusion: Repeated corneal cross-linking seems to be a safe and effective procedure to halt keratoconus progression after a primary corneal cross-linking failure.

RESUMO Objetivo: Avaliar a segurança e a eficácia a longo prazo da repetição do cross-linking corneano em olhos de crianças e adolescentes com ceratocone progressivo. Métodos: Estudo retrospectivo que incluiu nove olhos de nove pacientes consecutivos com ceratocone progressivo, que foram submetidos a retratamento com cross-linking corneano de 3,9 (variação de 1,6 a 5,6) anos após tratamento primário com cross-linking corneano. Todos os pacientes foram acompanhados por um período médio de 9,11 (variação de 6 a 11) anos após o primeiro tratamento e 5,44 (variação de 4 a 9) anos após retratamento com cross-linking corneano. Resultados: Nove olhos de nove pacientes (seis homens) com progressão do ceratocone foram submetidos a cross-linking corneano primário de 2009 a 2011. Apesar da estabilidade alcançada com o epi-off cross-linking corneano, o ceratocone continuou a progredir após algum tempo. O tempo médio para evidência documentada de progressão do ceratocone após cross-linking corneano primário foi de 3,9 (intervalo de 1,6 a 5,6) anos. Todos os olhos foram retratados com cross-linking corneano, assim que a progressão foi observada. Na última consulta de acompanhamento, 5,44 (variação de 4 a 9) anos após a repetição do cross-linking corneano, houve diminuição significativa de 2,02 D na média da curvatura máxima (p = 0,045) e 1,95 D na média da curvatura média (p = 0,007). Conclusão: O retratamento com cross-linking corneano parece ser um procedimento seguro e eficaz para interromper a progressão do ceratocone após falha primária do cross-linking corneano.

Caracterização da tuberculose no Brasil: avaliação das vulnerabilidades sociais, impacto econômico e políticas públicas / Characterization of tuberculosis in Brazil: assessment of social vulnerabilities, economic impact and public policies

Introdução: A tuberculose (TB) é uma das principais causas de morbidade e mortalidade em todo o mundo, representa um grande desafio para os sistemas de saúde pública, particularmente em países com altos índices de vulnerabilidade social, como o Brasil. A relação entre as condições socioeconômicas e os desfechos do tratamento da TB é complexa, envolve diversos fatores que influenciam tanto a exposição ao bacilo quanto o acesso e a adesão ao tratamento. Entender essa dinâmica é crucial para o desenvolvimento de estratégias eficazes de eliminação da TB que possam alcançar as populações mais acometidas pela doença. Neste contexto, a presente tese busca analisar a intersecção entre a vulnerabilidade social e os desfechos do tratamento da TB no Brasil, com o intuito de fornecer subsídios para políticas públicas e intervenções clínicas mais direcionadas e efetivas. Objetivo: Investigar a associação entre vulnerabilidade social e desfechos desfavoráveis do tratamento da TB no Brasil, abordar fatores de risco como diabetes e HIV, avaliar o impacto de tecnologias diagnósticas como o GeneXpert, desenvolver modelos preditivos para perda de seguimento e estimar o impacto econômico dos desfechos desfavoráveis, com o objetivo de aprimorar as estratégias de saúde pública e tratamento da TB. Método: Estudo observacional com dados secundários do Sistema de Informação de Agravos de Notificação (SINAN) de 2010 a 2022. Foram empregadas estatísticas descritivas, aprendizado de máquina e modelos de regressão para avaliar a associação entre variáveis clínicas, epidemiológicas, socioeconômicas e os desfechos do tratamento da TB. Tais estudos resultaram na composição de 7 manuscritos que abordam aspectos diferentes elaborados especificamente para informar desenho de políticas públicas. Resultados: Fatores socioeconômicos, como condições de moradia inadequadas, baixo nível educacional e vulnerabilidades específicas (como pessoas em situação de rua, vivendo com HIV e uso de drogas), estão significativamente associados a desfechos desfavoráveis do tratamento da TB. O retratamento, especialmente após a perda de seguimento, constitui um risco substancial para desfechos desfavoráveis. A implementação do GeneXpert melhorou a detecção de TB e TB-DR. Foi desenvolvido um modelo preditivo para a perda de seguimento durante o tratamento comparou diversos algoritmos de aprendizagem de máquina. Na análise econômica foi identificado para controle da TB no sistema de saúde no Brasil, um acúmulo de 109 milhões de dólares nos últimos 7 anos, sendo 19,8 milhões de dólares para casos de retratamento. Além disso, destaca-se o valor mínimo a ser investido por paciente de cada subpopulação estudada para atingir a meta de sucesso no tratamento proposto pela Organização Mundial da Saúde (OMS). Em nossos manuscritos o tratamento diretamente observado (TDO) foi o fator de proteção independentemente associado com as demais variáveis. Além disso, no âmbito econômico o TDO se mostrou uma estratégia efetiva, especialmente quando utilizado em populações vulnerabilizadas. Conclusões: Na tese, por meio dos resultados obtidos nos sete manuscritos, destacamos as variadas dimensões da vulnerabilidade social e seus impactos para os desfechos desfavoráveis do tratamento anti-TB. Os achados reforçam a importância de políticas de saúde pública como o TDO, especialmente em populações com vulnerabilidade e em retratamento, e a implementação do geneXpert para atingir melhores desfechos de tratamento e diagnóstico, respectivamente. O cálculo do custo da TB para o sistema de saúde destaca o impacto geral e evidencia o maior custo de populações vulnerabilizadas para atingir as metas de cura preconizadas pela OMS.(AU)

Introduction: Tuberculosis (TB) is one of the main causes of morbidity and mortality worldwide, representing a significant challenge for public health systems, particularly in countries with high levels of social vulnerability, such as Brazil. The relationship between socioeconomic conditions and TB treatment outcomes is complex, involving various factors that influence both exposure to the bacillus and access to and adherence to treatment. Understanding this dynamic is crucial for the development of effective TB elimination strategies that can reach populations most affected by the disease. In this context, this thesis aims to analyze the intersection between social vulnerability and TB treatment outcomes in Brazil, with the intention of providing insights for more targeted and effective public policies and clinical interventions. Objective: To investigate the association between social vulnerability and unfavorable TB treatment outcomes in Brazil, addressing risk factors such as diabetes and HIV, assessing the impact of diagnostic technologies like GeneXpert, developing predictive models for loss to follow-up, and estimating the economic impact of unfavorable outcomes, with the goal of enhancing public health strategies and TB treatment. Methods: Observational study using secondary data from the Information System for Notifiable Diseases (SINAN) from 2010 to 2022. Descriptive statistics, machine learning, and regression models were employed to assess the association between clinical, epidemiological, socioeconomic variables and TB treatment outcomes. These studies resulted in the composition of 7 manuscripts that address different aspects specifically designed to inform public policy design. Results: Socioeconomic factors, such as inadequate housing conditions, low educational level, and specific vulnerabilities (such as homeless individuals and those living with HIV), are significantly associated with unfavorable TB treatment outcomes. Retreatment, especially after loss to follow-up, poses a substantial risk for unfavorable outcomes. The implementation of GeneXpert has improved the detection of TB and drug-resistant TB (TB-DR). A predictive model for loss to follow-up during treatment compared various machine learning algorithms. Economic analysis revealed a substantial TB burden on the healthcare system, with an additional cumulative cost of $109 million over the past seven years, including $19.8 million for retreatment cases alone. Furthermore, it highlights the minimum investment required per patient from each subpopulation studied to meet the World Health Organization's (WHO) treatment success target. In our manuscripts, directly observed treatment (DOT) was independently associated with protection against unfavorable outcomes. Furthermore, in economic terms, DOT proved to be an effective strategy, especially when used in vulnerable populations. Conclusions: Through the results obtained in the 7 manuscripts, this thesis highlights the various dimensions of social vulnerability and their impacts on unfavorable TB treatment outcomes. The findings emphasize the importance of public health policies like DOT and the implementation of GeneXpert to achieve better treatment and diagnostic outcomes, respectively. The calculation of TB costs for the healthcare system demonstrates the overall impact and shows the higher costs associated with vulnerable populations to achieve WHO-recommended cure targets.(AU)