RESUMO
As lesões por luxação representam o grupo de lesões traumáticas dento-alveolares (LTDA) caracterizadas pelo dano simultâneo ao feixe vásculo-nervoso periapical e estruturas de sustentação dentária, em diferentes graus de complexidade, dependendo da força e direção do impacto. A patogenia das alterações pulpares decorrentes das luxações é resultado da extensão da lesão do feixe vásculo-nervoso apical e de sua capacidade de reparo, que determinam os seguintes desfechos para a polpa: manutenção da vitalidade pulpar, manutenção da vitalidade pulpar com obliteração da cavidade pulpar (OCP) ou a necrose pulpar. Entretanto, o processo de reparo pulpar pode envolver fenômenos intermediários cujos sinais e sintomas se modificam ao longo do período de acompanhamento até um diagnóstico definitivo. Sendo assim, do ponto de vista clinico, o tempo até a observação destas respostas, bem como seus fatores determinantes, representa uma informação tão importante quanto o próprio desfecho, pois tem influência direta na tomada de decisão sobre as condutas clinicas mais adequadas. A presente pesquisa consistiu num estudo clínico longitudinal retrospectivo com o objetivo de avaliar o prognóstico pulpar de dentes permanentes portadores de lesões por luxação, seu padrão cronológico e fatores determinantes, entre os pacientes atendidos na Clínica de Traumatismos Dentários da Faculdade de Odontologia da Universidade Federal de Minas Gerais no período de 2014 a 2022. Foram analisados prontuários de 224 pacientes com 427 dentes permanentes portadores de luxações, acompanhados por um período mediano de 1,4 anos (variação de 11 dias a 6,9 anos). O padrão de resposta pulpar foi classificado como manutenção da vitalidade pulpar, OCP e necrose pulpar através da avaliação clínica e radiográfica. Uma análise de sobrevivência utilizando-se o modelo de riscos competitivos foi realizada e curvas de função de incidência acumulada (FIA) foram construídas para se avaliar as taxas de cada um dos desfechos pulpares utilizando-se o estimador de Aalen-Johansen. O efeito de variáveis independentes, incluindo sexo, idade do paciente no momento do trauma, estágio de desenvolvimento radicular, grupo dentário, tipo de luxação, presença de fratura coronária concomitante e prescrição de antibioticoterapia sistêmica (ATS), foi avaliado utilizando-se um modelo multivariado de Cox causa-específico. Os dados foram analisados no programa estatístico R (versão 4.0.4, Viena, Áustria, 2021). Os resultados demonstraram manutenção da vitalidade pulpar em 38,2% da amostra (163 dentes), necrose pulpar em 28,1% (120 dentes) e OCP em 12,9% da amostra (55 dentes). O tempo mediano para o diagnóstico de necrose pulpar foi de 3 meses, enquanto o tempo para vitalidade pulpar foi de 8 meses e para OCP foi de 16 meses A probabilidade de manutenção de vitalidade pulpar diminuiu significativamente com a ocorrência de fraturas coronárias de esmalte e dentina concomitantes (HR 0,38 IC 95% [0,2 0,8] p = 0,006). A taxa de necrose pulpar foi significativamente menor em dentes com forame apical amplo (HR 0,62 IC 95% [0,4 0,96] p = 0,03) mas aumentou significativamente em dentes com luxações associadas às fraturas coronárias (HR 4,0 IC 95% [2,6 - 6,1] p = 0,001) e em dentes portadores de luxações intrusivas (HR 2,3 IC 95% [1,2 - 4,1] p = 0,007). Dentes portadores de luxações laterais ou extrusivas (HR 3,0 IC 95% [1,3 6,9] p = 0,001) ou com forame amplo (HR 2,4 IC 95% [1,2 4,7] p=0.01) apresentaram as maiores taxas de OCP.
Luxation injuries are a group of traumatic dental injuries (TDI) that involve damage to both the pulp and periodontium, with different degrees of complexity. Pulp damage results from injury to the apical neuro-vascular bundle and, depending on the repair potential, may result in the following outcomes: maintenance of pulp vitality, maintenance of pulp vitality with pulp canal obliteration (PCO) or pulp necrosis. However, the pulp healing process may involve intermediate and reversible phenomena whose signs and symptoms mimic pulp necrosis, rendering the timing of these events critical for decision-making during the follow-up period. The present study consisted in a retrospective cohort to evaluate the pulpal prognosis of luxated permanent teeth, its chronological pattern and predictive factors, among patients treated at the Dental Trauma Clinic of the Federal University of Minas Gerais, from 2014 to 2021. Records of 224 patients with 427 permanent teeth with luxations, followed up for a median period of 1.4 years (ranging from 11 days to 6.9 years) were analysed. Pulp outcomes - maintenance of pulp vitality, PCO and pulp necrosis were defined trough clinical and radiographic evaluation. A competing risk survival analysis was performed and cumulative incidence function (CIF) curves were build using the Aalen-Johansen estimator to assess the rates of each of the pulp outcomes during the follow-up period. The effect of independent variables including patient's gender and age at the time of trauma, tooth group and stage of root development, type of luxation, concomitant injuries, systemic antibiotic therapy (SAT) prescription, was evaluated using a cause-specific Cox regression model. Data were analysed in the R statistical program (version 4.0.4, Vienna, Austria, 2021). The results showed maintenance of pulp vitality in 38.2% of the sample (163 teeth), pulp necrosis in 28.1% (120 teeth) and OCP in 12.9% of the sample (55 teeth). The median time for the diagnosis of pulp necrosis was 3 months, while the time for pulp vitality was 8 months and for PCO was 16 months. The hazards of pulp vitality significantly decreased with the occurrence of concomitant coronal fractures (HR 0 .38 95% CI [0.2 0.8] p = 0.006). The hazards of pulp necrosis was significantly lower in teeth with a wide apical foramen (HR 0.62 95% CI [0.4 0.96] p = 0.03) but increased significantly in teeth with luxations associated with crown fractures (HR 4.0 CI 95% [2.6 - 6.1] p = 0.001) and in teeth with intrusive displacement (HR 2.3 CI 95% [1.2 - 4.1] p = 0.007). Teeth with lateral or extrusive luxations (HR 3.0 CI 95% [1.3 6.9] p = 0.001) or with a wide foramen (HR 2.4 CI 95% [1.2 4.7] p =0.01) showed the highest rates of PCO.
Assuntos
Avulsão Dentária , Cicatrização , Traumatismos Dentários , Medição de Risco , Polpa DentáriaRESUMO
BACKGROUND/AIM: The literature on the pathogenesis of extrusive dental luxation has been focused on periodontal tissue responses, with little attention given to the pulp. The aim of this study was to evaluate the response of dental pulp of teeth following extrusive luxation in a rat model. MATERIAL AND METHODS: The maxillary right central incisors of 30 rats were extrusively luxated and repositioned after 5 minutes. The animals were euthanized after 7, 15, and 30 days to provide three groups: I, II, and III, respectively (n = 10). Histological sections were stained with H and E for histomorphometric analysis of the odontoblast layer, reparative dentin deposition, Hertwig's epithelial root sheath, pulp necrosis, and periapical inflammatory infiltrate. RESULTS: In most cases, new vascular formation occured in association with reparative dentin deposition on the root walls and within the pulp. In some cases, dentin deposition occupied the entire pulp space over time, with no other types of non-odontogenic hard tissues being observed. Pulp necrosis with the presence of periapical inflammatory infiltrate was also observed in a few cases. No statistical differences were observed among the studied groups. CONCLUSIONS: Following extrusive luxation, calcific metamorphosis of the pulp is very likely to occur.
Assuntos
Necrose da Polpa Dentária , Polpa Dentária , Avulsão Dentária , Animais , Dentina , Incisivo , RatosRESUMO
Los traumatismos dentoalveolares que afectan a escolares pueden involucrar a los tejidos blandos y/o duros de las piezas primarias y permanentes jóvenes. Las causas por las que se producen son múltiples e incluyen caídas, accidentes en el hogar, actividad deportiva en el colegio o el club, accidentes de tránsito. El objetivo de este trabajo es presentar la resolución y el seguimiento a dos años de dos situaciones clínicas de traumatismos dentoalveolares en pacientes escolares que concurrieron a la Universidad de Buenos Aires, Facultad de Odontología, Odontología Integral Niños (AU)
Dentoalveolar trauma in schoolchildren can involve soft and/or hard tissues of deciduous and young permanent teeth. It has multiple causes, including falls, home accidents, sports accidents at school or at a club, and car accidents. The aim of the present work was to show treatmentand two-year clinical follow up of dentoalveolar trauma in schoolchildren seen at the Universidad de Buenos Aires, Facultad de Odontología, Odontología Integral Niños (AU)
Assuntos
Humanos , Masculino , Criança , Fraturas dos Dentes , Avulsão Dentária , Traumatismos Dentários , Argentina , Faculdades de Odontologia , Seguimentos , Assistência Odontológica para Crianças , Capeamento da Polpa Dentária , Restauração Dentária Permanente , Tratamento de Emergência , Ferula , Cimentos de Ionômeros de VidroRESUMO
BACKGROUND/AIM: The assessment of pulp vitality is one of the major challenges in dental traumatology due to the temporary loss of sensibility after trauma and because of the limitations of conventional pulp tests. The aim of this study was to evaluate pulpal response to sensibility tests and to determine their accuracy after crown fractures and luxation injuries. MATERIALS AND METHODS: A total of 121 permanent anterior teeth from 78 patients treated at the Dental Trauma Clinic of the Federal University of Minas Gerais were evaluated. Responses to pulp sensibility tests were monitored for a minimum period of 24 months or until the diagnosis of pulp necrosis. RESULTS: At the first appointment, 68 teeth responded positively to sensibility tests, one tooth was necrotic and 52 teeth did not respond to sensibility tests but showed no other signs of necrosis. The initial lack of response was not associated with age (P = 0.18), but was related to the presence of luxation (P < 0.001). At the final appointment, 87 teeth were classified as vital and 31 were classified as non-vital. While a positive response shortly after trauma was a good predictor of vitality, a lack of response was not associated with subsequent necrosis. The final pulpal condition of the teeth that initially did not respond was associated with the type of injury, as displaced teeth tended to develop necrosis (P = 0.008). The accuracy of each sensibility test at the initial and final appointments was, respectively, 55.1% and 67.8% for the heat test, 55.9% and 77.9% for the cold test, and 57.6% and 89% for the electrical test. CONCLUSIONS: A temporary loss of sensibility was a frequent finding during post-traumatic pulpal healing, especially after luxation injuries. All sensibility tests presented low accuracy shortly after trauma. The electrical test provided the best support for pulpal diagnosis after long-term follow up. The clinician must be aware of additional signs of crown discoloration and radiographic changes before initiating endodontic treatment.