Termo de consentimento livre e esclarecido aos usuários de clínicas odontológicas brasileiras: aspectos éticos e legais

O consentimento do paciente antes do início de qualquer procedimento é uma condição a ser respeitada pelos profissionais da odontologia, sem nenhuma exceção. É necessário que o paciente esteja ciente de seu status de saúde, de suas necessidades específicas, do propósito de cada tratamento, conheça os planejamentos alternativos (incluindo o não tratamento), saiba do seu prognóstico, riscos, consequências, limitações e se conscientize das suas responsabilidades e as do seu cirurgião-dentista, proporcionando o sucesso do tratamento. O termo de consentimento livre e esclarecido (TCLE) visa fortalecer e esclarecer a posição do paciente, estabelecendo os direitos e deveres de ambas as partes paciente e profissional. O conhecimento integral do tratamento diminuirá a ansiedade do paciente e as complicações de tratamento, promoverá maior qualidade dos serviços odontológicos e maior satisfação do dentista e do paciente. Entretanto, no Brasil, poucos artigos são encontrados e existem alguns problemas éticos envolvendo as clínicas odontológicas, no que diz respeito a este documento de esclarecimento para o paciente. Diante disso, este trabalho tem por objetivo realizar uma revisão crítica sobre o tema abordado, demonstrando a importância do TCLE na clínica odontológica brasileira e na vida profissional dos cirurgiões-dentistas.

Variáveis relevantes no tratamento da má oclusão de Classe II

Os resultados do tratamento da má oclusão de Classe II podem ser influenciados por características que são inerentes ao paciente - como a idade, a severidade da má oclusão e o grau de colaboração - ou, ainda, por fatores relacionados à conduta do profissional - como a escolha do protocolo de tratamento. Basicamente, o tratamento da Classe II pode ser realizado sem extrações ou com extrações de dois ou quatro pré-molares. Contudo, uma maior proporção de sucesso do tratamento pode ser esperada com extrações de dois pré-molares superiores, independentemente do padrão facial e da relação maxilomandibular. Considerando esta revisão, pôde-se concluir que os resultados oclusais do tratamento da Classe II são fortemente influenciados pelo protocolo de tratamento, enquanto o padrão facial não parece exercer uma influência significativa.

Termo do 1º Consenso em Disfunção Temporomandibular e Dor Orofacial

O Termo do 1º Consenso em Disfunção Temporomandibular e Dor Orofacial* foi criado com o propósito de substituir divergências por evidência científica dentro dessa especialidade da Odontologia. O documento oferece informações claras e fundamentadas para orientar o cirurgião-dentista e demais profissionais de saúde sobre os cuidados demandados pelo paciente, tanto no processo de diagnóstico diferencial quanto na fase de aplicação das terapias de controle da dor e disfunção. O Termo foi aprovado no mês de janeiro de 2010 em reunião realizada durante o Congresso Internacional de Odontologia do Estado de São Paulo e converge o pensamento dos profissionais mais conceituados do Brasil na especialidade Disfunção Temporomandibular e Dor Orofacial.

Clinical, microscopic and imaging findings associated to Mccune-Albright syndrome: report of two cases

McCune-Albright syndrome is characterized by the triad café-au-lait cutaneous spots, polyostotic fibrous dysplasia and endocrinopathies. This article presents two cases of McCune-Albright syndrome in a middle-aged woman and a young girl. Both patients presented café-au-lait spots on the face and other parts of the body and expansion of the mandible with radiopaque-radiolucent areas with ground-glass radiographic appearance, and were diagnosed as having fibrous dysplasia and endocrine disorders. The patient of Case 1 had fibrous dysplasia on the upper and lower limbs, thorax, face and cranium, early puberty, hyperglycemia, hyperthyroidism and high serum alkaline phosphatase levels. The patient of Case 2 presented lesions on the upper limbs and evident endocrine disorders. In both cases presented in this article, the initial exam was made because of the mandibular lesion. However, a diagnosis of fibrous dysplasia must lead to investigation of the involvement of other bones, characterizing polyostotic fibrous dysplasia, which is manifested in a number of diseases. An accurate differential diagnosis is mandatory to determine the best treatment approach for each case.

Rehabilitation of severely resorbed edentulous mandible using the modified visor osteotomy technique

The prosthetic rehabilitation of an atrophic mandible is usually unsatisfactory due to the lack of support tissues, mainly bone and keratinized mucosa for treatment with osseointegrated implants or even conventional prosthesis. The prosthetic instability leads to social and functional limitations and chronic physical trauma decreasing the patient's quality of life. A 53-year-old female patient sought care at our surgical service complaining of impairment of her masticatory function associated with the instability of the lower total prosthetic denture. The clinical and complementary exams revealed edentulism in both arches, while the mandibular arch presented severe reabsorption resulting in denture instability and chronic trauma to the oral mucosa. The proposed treatment plan consisted in the mandibular rehabilitation with osseointegrated implants and fixed Brånemark's protocol prosthesis after mandibular reconstruction applying the modified visor osteotomy technique. The proposed technique offered predictable results for reconstruction of the severely resorbed edentulous mandible and posterior rehabilitation with osseointegrated implants.

Orbital abscess after facial trauma

This paper reports a rare case of acute severe orbital abscess manifested 2 days after a facial trauma without bone fracture in a 20-year-old Afro-American female. The symptoms worsened within the 24 h prior to hospital admission resulting in visual disturbances such as diplopia and photophobia. The clinical findings at the first consultation included fever, periorbital swelling and redness, ptosis, proptosis and limitation of ocular movements upwards, downwards, to the right and to the left. Computed tomography scan showed proptosis with considerable soft tissue swelling on the left side and no fracture was evidenced in the facial skeleton, including the zygomatic-orbital complex. After hospital admission and antibiotic therapy intravenously the patient was conducted to the operation room and submitted to incision and drainage under general anesthesia. The orbit was approached thorough both eyelids and the maxillary sinus was reached only through the Caldwell-Luc approach. The postoperative period was uneventful and the rapid improvement of symptoms was remarkable. Visual acuity and ocular motility returned to the normal ranges within 2 days after the surgical intervention. After 12 postoperative days, the patient presented with significative improvement in the ptosis and proptosis, and acceptable scars.

Large apical periodontitis healing following root canal dressing with calcium hydroxide: a case report

PURPOSE: The objective of this paper is to report the clinical case of a patient who presented a chronic apical periodontitis, arising from internal inflammatory resorption followed by pulp necrosis, and a long-term success of a root canal therapy using calcium hydroxide as root canal dressing. CASE DESCRIPTION: A 20-year-old male patient presented for routine dental treatment. By radiographic examination we noted an extensive radioluscent area, laterally to the permanent maxillary right lateral incisor, with possibility of communication with the lateral periodontium, suggestive of a chronic apical periodontitis. Due to external root resorption detection, we used a calcium hydroxide root canal dressing, changed every 15 days, for a period of 2 months. Root canal filling was performed using gutta-percha cones by lateral condensation technique Radiographic follow up held after 19 years of treatment indicated a periodontium in conditions of normality, with the presence of lamina dura. CONCLUSION: Calcium hydroxide is a suitable material to be used as root canal dressing in teeth with apical periodontitis. Long-term evaluation demonstrated the satisfactory clinical outcome following root canal treatment.

Extrações dentárias em Ortodontia: avaliação de elementos de diagnóstico

Algumas más oclusões exigem do ortodontista capacidade de diagnóstico para decidir pela melhor maneira de tratar o paciente. O objetivo dos autores deste artigo foi apresentar casos clínicos e discutir alguns elementos de diagnóstico utilizados na elaboração do plano de tratamento, auxiliando na decisão de extrair dentes. Foi dada ênfase em cada elemento de diagnóstico: aspectos relacionados à cooperação, discrepância de modelo, discrepância cefalométrica e perfil facial, idade esquelética (crescimento) e relações anteroposteriores, assimetrias dentárias, padrão facial e patologias. Sugere-se que a associação dos aspectos citados é importante para a decisão correta. Todavia, algumas vezes, uma característica, por si só, pode definir o plano de tratamento.

Orthodontic-surgical treatment of class III malocclusion with mandibular asymmetry

Class III skeletal malocclusion may present several etiologies, among which maxillary deficiency is the most frequent. Bone discrepancy may have an unfavorable impact on esthetics, which is frequently aggravated by the presence of accentuated facial asymmetries. This type of malocclusion is usually treated with association of Orthodontics and orthognathic surgery for correction of occlusion and facial esthetics. This report presents the treatment of a patient aged 15 years and 1 month with Class III skeletal malocclusion, having narrow maxilla, posterior open bite on the left side, anterior crossbite and unilateral posterior crossbite, accentuated negative dentoalveolar discrepancy in the maxillary arch, and maxillary and mandibular midline shift. Clinical examination also revealed maxillary hypoplasia, increased lower one third of the face, concave bone and facial profiles and facial asymmetry with mandibular deviation to the left side. The treatment was performed in three phases: presurgical orthodontic preparation, orthognathic surgery and orthodontic finishing. In reviewing the patient's final records, the major goals set at the beginning of treatment were successfully achieved, providing the patient with adequate masticatory function and pleasant facial esthetics.

Responsabilidade civil do cirurgião-dentista: a importância do assistente técnico

INTRODUÇÃO: a responsabilidade do cirurgião-dentista pode ser entendida como obrigações de ordem penal, civil, ética e administrativa, às quais está sujeito no exercício de sua atividade. Assim, se comprovado um resultado lesivo ao paciente - por imprudência, imperícia ou negligência -, o cirurgião-dentista estará sujeito às penalidades previstas no Código Civil, sendo obrigado a satisfazer o dano e indenizar segundo a consequência provocada. Em processos cíveis, as partes poderão contratar um assistente técnico para fornecer, aos respectivos advogados, conhecimentos técnicos e científicos inerentes ao tema. OBJETIVO: informar sobre a importância da atuação de assistentes técnicos em processos cíveis, propiciando às partes uma maior compreensão dos aspectos técnicos, éticos e legais. CONCLUSÃO: há a necessidade de um maior conhecimento, por parte dos profissionais em Odontologia, sobre os aspectos éticos e legais que norteiam a profissão.

Management of a complex dentoalveolar trauma: a case report

This paper describes the case of a 12-year-old male patient who presented a severe lateral luxation of the maxillary central incisors due to a bicycle fall. Treatment involved suture of the soft tissues lacerations, and repositioning and splinting of the injured teeth, followed by endodontic treatment and periodontal surgery. After a 2-year follow-up, clinical and radiographic evaluation revealed that the incisors presented satisfactory esthetic and functional demands.

T-Bar clasp-retained removable partial denture as an alternative to implant-based prosthetic treatment

This article reports the case of a 55-year-old female patient who presented with unsatisfactory temporary crowns in the right mandibular premolars and molars, and a premolar-to-molar fixed partial denture in the left side. The clinical and radiographic examinations revealed a fracture of the left first premolar that was a retainer of the fixed partial denture and required extraction. Initially, the acrylic resin crowns were replaced by new ones, and a provisional RPD was made using acrylic resin and orthodontic wire clasps to resolve the problem arising from the loss of the fixed partial denture. Considering the patient's high esthetic demands, the treatment options for the definitive prosthetic treatment were discussed with her and rehabilitation with implant-supported dentures was proposed because the clinical conditions of the residual alveolar ridge were suitable for implant installation, and the patient's general health was excellent. However, the patient did not agree because she knew of a failed case of implant-retained denture in a diabetic individual and was concerned. The patient was fully informed that implant installation was the best indication for her case, but the arguments were not sufficient to change her decision. The treatment possibilities were presented and the patient opted for a clasp-retained removable partial denture (RPD) associated with the placement of crowns in the pillar teeth. The temporary RPD was replaced by the definitive RPD constructed subsequently. Although RPD was not the first choice, satisfactory esthetic and functional outcomes were achieved, overcaming the patient's expectations. This case report illustrates that the dentist must be prepared to deal with situations where, for reasons that cannot be managed, the patient does not accept the treatment considered as the most indicated for his/her case. Alternatives must be proposed and the functional and esthetic requirements must be fulfilled in the best possible manner.

Endodontic treatment of dental formation anomalies

PURPOSE: Dental fusion is defined as the union of two dental germs at some stage of their development. The aim of this article is to report the endodontic treatment of two clinical cases of dental fusion. CASE DESCRIPTION: In the first case, the patient was referred by an orthodontist for endodontic treatment of tooth 12, which was fused to 13. Surgical separation and later replacement of the involved elements in the dental arch was indicated. In the second case, the patient sought dental attendance due to spontaneous pain. In the radiographic exam, gemination in tooth 11 and fusion of 21 with a supernumerary tooth was observed. The fused teeth were endodontically treated, and patients were referred to other dental specialties to reestablish esthetics and function. CONCLUSION: The dentist must be able to diagnose, differentiate and treat these dental anomalies adequately, with the goal of maintaining patients' oral health.

Diagnosis and root canal treatment in a mandibular premolar with three canals

This paper presents a case report of a left mandibular second premolar with three canals and three different apical foramina. A 39-year-old male patient presented to our clinic with pain in the mandibular left second premolar. Initially, pain was caused by cold stimulus and later was spontaneously. The intraoral clinical examination revealed a fractured amalgam restoration with occlusal caries. Percussion and cold (Endo-Frost) tests were positive. The radiographic examination showed the presence of two roots. The probable diagnosis was an acute pulpitis. After access cavity, it was observed remaining roof of the pulp chamber and mild bleeding in the tooth lingual area, indicating the possible presence of a third canal. The endodontic treatment was completed in a single session using Root ZX apex locator and K3 NiTi rotary system with surgical diameter corresponding to a .02/45 file in the three canals and irrigation with 1% sodium hypochlorite. The canals were obtured with gutta-percha cones and Sealer 26 using the lateral condensation technique. After 1 year of follow-up, the tooth was asymptomatic and periapical repair was observed radiographically. Internal alterations should be considered during the endodontic treatment of mandibular second premolars. The correct diagnosis of these alterations by the analysis of preoperative radiographs can help the location of two or more canals, thereby avoiding root therapy failure.

Bite force in temporomandibular dysfunction (TMD) and healthy complete denture wearers

The signs and symptoms of temporomandibular dysfunction (TMD) may contribute to reduce bite force and muscular activity. The aims of this study were to compare bite force in complete denture wearers with TMD (TMD group) and without TMD (healthy group).The TMD group consisted of 9 individuals, who had worn a maxillary and a mandibular complete removable denture for more than 10 years. The healthy group consisted of 9 participants who wore dentures and had satisfactory interocclusal and maxillomandibular relationship. Helkimo Index was used to analyze the dysfunction level. Maximum bite force was measured using a digital dynamometer with capacity of 100 kgf and adapted to oral conditions.The TMD group presented smaller mean bite force values than the healthy group, though without statistical significance (p>0.05). This outcome suggests that the TMD signs and symptoms and the structural conditions of the dentures did not affect the maximal bite force of complete denture wearers.