Riscos associados à extração de terceiros molares por indicação ortodôntica

Dissertação para obtenção do grau de Mestre no Instituto Universitário Egas MonizAtualmente, não há uma unanimidade entre os médicos dentistas, quanto à extração ou preservação dos terceiros molares. Os terceiros molares retidos, semi-retidos devem ser sempre extraídos? Em geral, o terceiro molar, é o último dente a erupcionar na arcada dentária e é comum estar retido, semi-retido, incluso ou impactado e estes são termos que podem ser utilizados. Por definição, a retenção dentaria é a falha na erupção do dente no tempo esperado, não estando presente na cavidade bucal. A exodontia do terceiro molar é uma cirurgia simples, porém é uma intervenção invasiva podendo trazer dano à saúde bucal do paciente. Com isso, o prognóstico cirúrgico dá-se através de exames clínicos e radiográficos, nos quais se pode classificar o nível de dificuldade e o impacto no organismo deste ato cirúrgico. As indicações para exodontias dos terceiros molares são: os quistos odontogénicos, doença periodontal, possibilidade de cárie em um dente adjacente ou no próprio terceiro molar, reabsorção radicular do dente adjacente ou causas ortodônticas. No entanto, é preciso avaliar se este ato cirúrgico tem risco de gerar problemas graves ao paciente que superem o benefício da exodontia. Hemorragias, trismo, dor, edema, infeções (alveolites seca e supurativa), lesão do nervo alveolar inferior, lesão em dentes adjacentes, fratura óssea do angulo da mandíbula, comunicação do seio maxilar com a cavidade oral, problemas periodontais em dentes adjacentes, deslocamento de dentes para regiões anatómicas nobres, são potenciais complicaçõespós-cirúrgicas. O objetivo deste estudo é avaliar os riscos associados à extração dos terceiros molares por indicação ortodôntica e suas consequências. Portanto, é de fundamental importância esses fatores serem avaliados no planeamento cirúrgico, prevenindo e controlando ao máximo as hipóteses de intercorrências indesejáveis do ato cirúrgico.Currently, there is no unanimity among the dental surgeons, regarding the extraction or preservation of the Third Molars. Should retained third molars, semiretained ones always be extracted? In general, the third molar is the last tooth to erupt in the dental arch and it is common to be retained, even semi-retained, included or impacted and these are terms that can be used. By definition, dental retention is the failure of the tooth eruption within the expected time, not being present in the buccal cavity. Third molar extraction is a simple surgery, but it is an invasive intervention that can harm the patient's oral health. Thus, the surgical prognosis is made through clinical and radiographic examinations, in which the level of difficulty and the impact on the organism of this surgical act can be classified. Indication for third molar extraction are: odontogenic cysts, periodontal diseases, possibility of dental caries in the adjacent tooth or in the third molar itself, root reabsorption of the adjacent tooth or orthodontic causes. However, it is necessary to evaluate if this surgical act may cause serious problems for the patient that outweigh the benefit of the extraction. Hemorrhages, trismus, pain, edema, infections (dry and suppurative alveolitis), lower alveolar nerve injury, adjacent tooth injury, bone fracture of the mandible angle, communication of the maxillary sinus with the oral cavity, periodontal problems in adjacent teeth, teeth displacement to noble anatomic regions, are potential postoperative complications. The aim of this study is to evaluate the risks associated with the extraction of third molars by orthodontic indication and its consequences. Therefore, it is of fundamental importance to evaluate these factors at the surgical planning, in order to prevent and control as much as possible the chances of undesirable intercurrences of the surgical act

Núcleos de Ensino da Unesp: artigos 2008

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

International audienceBackground: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society