Antes de mais, é uma honra criar este meu primeiro POST que certamente se envolverá por brilhantes e bem resolvidos casos clínicos que muito provávelmente invadirão este novo e tão promissor projecto. Root Canal Paradise lives up to its name….
Vou narrar este caso realmente como ocorreu, não embezando, não romanceando apenas descrevendo o mais intimamente possivel… porque não pretendo que seja um desfile de vaidades mas sim um espaço de reflexão, de troca de sabedoria e intuições.
Terça-feira.
Paciente enviado por um Colega Generalista. A paciente foi submetida a radio e quimioterapia há 6 meses, e apareceu na consulta com uma coroa Richmond… na mão. Segundo a paciente a coroa caía várias vezes e foi-lhe explicado pelo seu dentista que seria complicado fazer um espigão maior com a presença do instrumento fracturado. Observando o Rx inicial, podemos concluir que o trajecto do espigão é já um falso trajecto e que há restos de material de cimentação no canal. O instrumento fracturado é uma lima Hedstroem que pode estar dentro do seio e que pode estar encravada no osso periapical, já que sendo um canal recto não haveria grande razão para esta fractura. Planeamento: cirurgia apical ou exodontia (com história de radio e quimio recentes?), remoção do instrumento via ortogonal? Sabemos que estamos perante uma situação borderline Endo/Implante mas os condicionalismos impõe-nos uma abordagem conservadora.
Sómente após 1 hora de trabalho com ultrassons (ponta EMS ET-40) foi-me possivel ver o instrumento. Havia muita resina dentro do canal e um falso trajecto que sempre nos faz “perder o norte”. Nos minutos seguinte o instrumento foi desbloqueado da resina e comecei a aplicar-lhe forças ultrassónicas. Com o ultrassons percebi que o instrumento estava preso em tecidos duros provávelmente do periápice. Neste segundo Rx é possivel perceber que o instrumento se afundou no seio. Nesta fase deixei de lado o ultrassons e recorri ao IRS e ao “velhinho” Masseram. Entre tentativas desesperadas percebi que o êmbolo do sistemas de tubos empurrava o instrumento para apical… o que me trouxe uma nova variante… o instrumento estava solto no ápice e dentro do seio. Colei o Richmond com ionomero de vidro, radiografei e assim dei por terminada a primeira consulta.
Fui para casa com esta imagem.
Reflecti novamente nas alternativas… Falei com o Referenciador, que me disse que o Oncologista teria dito que não havia problema em se fazer uma cirugia apical. Mas isso não me tranquilizou até porque o instrumento já esava quase mais no seio do que no canal. Expliquei ao Referenciador a necessidade de repetir a coroa já que esta estava nitidamente desadaptada.
Terça-feira, uma semana depois.
Comecei a consulta decidido que seria desta. Não usei ultrassons mas ao mesmo tempo estava com medo de usar os sistemas de tubos, já que o êmbolo teria empurrado o instrumento e agora este estava à beira do precipício, à espera do último toque para cair no seio. (ainda me passou pela cabeça que saíria pelo nariz…:)).
Estava numa encruzilhada, sabia que não podia pressionar o instrumento e conseguia ver com o microscópio o seu envolvimento pelo tubo oco do IRS… e lembrei-me de Peter Cancellier. Envolvemo-nos em gadgets sem dar conta que às vezes o mais simples é o mais indicado. Desesperado, parti o meu IRS (que muitos muitos anos me acompanhou), pequei naquele tubo oco e enchi-o de supercola do chinês do fundo da rua. Acreditem que não foi à primeira mas talvez à 10ª tentativa. Deste modo estava certo que não faria força apical no instrumento. E Voilá!
Rx comprovando a ausência do instrumento
Após o protocolo de irrigação, foi feita obturação com System B, procurando algum stop apical (já que estavamos com um calibre apical 60)e conveniente “Tug-back”.
Foi feito um selamento intracanalar com resina Flow cobrindo a gutta-percha e a coroa foi cimentada com ionomero de vidro. Neste momento liguei para o Referênciador para que este a recebesse ainda no próprio dia.
Rx final.
Conclusão: há por vezes condicionantes que exigem de nós um planeamento e até mesmo alterações de protocolos que muito certamente separam o sucesso do insucesso. Este BrainStorming deverá contemplar os cenários, precaver os erros e antecipar os sucessos. Só assim podemos ser e querer ser verdadeiros Endodontistas.
Filipe Aguilar
Fantástico.
É isto que faz da endoodntia um desafio, uma actividade fascinante, difícil, emocionante e que às vezes nos deixa meio panóicos.
Ainda iniciei estas lides mais a sério há pouco tempo mas está-me a parecer que o bichinho já germina.
Mais uma vez parabéns
Sarah: The word Salvia refers to the Sage genus of palnts, including the Salvia offiadcinalis species that you put in your stuffing. This genus also conadtains many more species though, including Salvia divinorum. Here’s aa0link to the Salviaa genus wikiadpedia article so you can get an idea for how many other members of this genus therea0are.Salvia divinorum is psyadchoadactive, but it is ceradtainly no alternadative to canadnabis (or LSD for that matter). For aa0bit more informadaadtion on Salvia divinorum itself you might like to read “What is Salvia?” (including an hour long docaduadmentary) or have aa0look at aa0presentadaadtion Ia0gave on it recently. You can also read loads of Salvia divinorum experadiadence reports on Salvia Trip to give you aa0better idea of just how unique this planta0is.As for ebay, who knows why they banned it. Salvia divinorum is illegal in aa0few counadtries and aa0few states in the US, so that might be the reason. This guy got into some hot water with the dried leaf he bought from ebay, so that might have conadtribaduted to their decision too.
Hi, I really wanted to answer your question. But I am not sure if it will been seen by some people as a violation of the rules here. So, what I can do is give you some handy links, where you can find ways to make salvia extract yourself. It’s really kinda easy, what you will need is ethanol, about 50 grams of leaves, and some glass jars. If you are gonna smoke your own extract, use a strong lighter, like a jetflame. Salvinorin doesn;’t come free at the normal temperature of a lighter, it needs to burn very hot.To dry the leaves is simple. Just dry them, you can put them on top of each other in between toilet paper. If they are dry, put them in a food container or something simular. Good luck! And beware, using salvia is very different then weed! It can be very strong, so know what you are doing!
works like a dream. The boxes are easy, the method is brilliant, but the mix was a different story. 1/3 compost, 1/3 peat moss, and 1/3 vermiculite, agricultural gauge, which means chunky bits of vermiculite, not fine.Everything was going smoothly until we tried to find vermiculite. We checked all the Home Depot type megastores, the little stores, gardening supply, everything he says to do in the book, to no avail. When we did find it at a pool supply company, we were informed we would have to pay $125 shipping to get it here from Atlanta. Online did not prove much better because we are growing a garden to save money, not spend more.Finally, we had to settle for the fine stuff from a pool supply company which was pretty fine grade, but made the most luxurious and easy to work with soil I have ever seen. It was worth the search, but here’s the problem I had:Now Mel addresses the vermiculite availbility on his website, saying that it is now available in Utah, with no shipping. Utah, huh? No problem! Except we live in Memphis. When we wrote the website explaining our trouble finding it at a reasonable cost, we did get a quick reply (to all our questions, btw) and they sent us a pre-formatted response telling us to check at the home supply mega-stores because he’s never found one that didn’t carry it. My question is if it’s everywhere then why have the pre-formatted response? And when he addresses finding a substitute, says that yes, you can substitute perlite (which is much easier to find) but he says don’t do it because it makes him sneeze, it doesn’t hold moisture as well as vermiculite, and he doesn’t like the way that it feels or how it makes the garden look.Well. Aren’t we a just a bit Martha. Lemme just write that check for $185 to the pool supply with the agricultural grade.So that being said, why did I give it five stars? Because other than finding the vermiculite–which we finally did in fine grade for $28 for four boxes–I’ve rarely seen a more reader-friendly book! It comes complete with layout pages, very consise planting guides, even planting time tables for your area and the amount of time you can store your seeds! If you have never gardened before or started a garden that eventually left you frustrated, then this is the book for you! I just think that you should check your area for agricultural grade vermiculite before you buy the book. But once that little snafu is over, you are going to be amazed at how brilliant and easy this book makes successful gardening.I highly recommend this method for busy people and parents like myself. It is wonderfully easy to maintain, makes loads of produce, and looks very attractive. Two green thumbs way, way up.To see my boxes and my experience with the All New Square Foot Gardening method, check out my frugal/tipping blog at […].Help other customers find the most helpful reviews Was this review helpful to you? | Â
That saves me. Thanks for being so sensible!
This is way more helpful than anything else I’ve looked at.
Such a deep answer! GD&RVVF
I was drawn by the honesty of what you write
I can’t believe you’re not playing with me–that was so helpful.
If time is money you’ve made me a wealthier woman.
I don’t know who you wrote this for but you helped a brother out.
That’s the perfect insight in a thread like this.
Kick the tires and light the fires, problem officially solved!
The ability to think like that is always a joy to behold
Well macadamia nuts, how about that.
Your post captures the issue perfectly!
Thanks for sharing. Your post is a useful contribution.
I see, I suppose that would have to be the case.
When you think about it, that’s got to be the right answer.
Well I guess I don’t have to spend the weekend figuring this one out!
Brutal! Parabéns!
The Internet is new to me, being that I just retired. I can see that there is a rich divsierty in the blogs I am reading and I am trying to leave some comment whereever I visit. I don’t understand everything that is in all the blogs that I read, but I like your presentation here in this blog. Well you know I have my own blog and website now. It is fun, to be sure. There was a place to include an email and address, so I have done that. I hope you approve that I did this. It seems to be customary so I went ahead with it. TheVeryBest2You 13 9
The Internet is new to me, being that I just retired. I am rediang blogs on many topics, and commenting too. You have made your blog more interesting than most that I read. Thanks for that. I am approaching this from all sides, sonce I recently started my own website with its own blog. I have incuded a website and email address. I think it is ok that I incuded them since there seems to be a place to do that. Hope so anyway. TheVeryBest2You 13 9
I have pvnh I was 13 when the symptoms srttaed showing. Since then it has been 1 thing after another that seems to be wrong with me. I have a daughter who will be 8 in October and she is not showing any signs that she has it. So, all I can do is pray & ask for prayers that this condition doe not affect my daughter. aEven though my mother and I are affected by it.