Traducido del Texto "Endodontics" de Arnaldo Castellucci MD, DDS Vol. 1. Primera Ed. 2.004 Traducción: Dr. Carlos Heilborn. Odontólogo. Especialista en Endodoncia. Asunción - Paraguay EL SÍNDROME DEL DIENTE FISURADO Uziel Blumenkranz S. DDS Si uno considera las varias quejas de los pacientes con diferentes formas de patología pulpar, por ej. sensibilidad al frío en la hiperemia o sensibilidad al calor en las pulpitis; o de patología peri apical, por ej. dolor desencadenado por presión en una periodontitis o absceso, uno puede concluir que éstos no pueden coexistir en el mismo diente. Mientras el paciente puede manifestar que el diente es sensible al calor, frío y presión, esto se debe generalmente a la condensación de síntomas de odontalgias previas. Sin embargo, existe un caso en el cual estos tres síntomas pueden originarse y coexistir en un mismo diente. Esto se conoce como el "síndrome del diente fisurado". Introducción Hasta el año 1.964 se han sugerido muchos nombres para esta condición. Pero fue Cameron quien introdujo el término "síndrome del diente fisurado", agregando que "el factor más importante para el diagnóstico del diente fisurado es el conocimiento de que estas fisuras suceden". Aunque se han escrito muchos artículos sobre este tema desde entonces, muchos pacientes con este síndrome están sin diagnóstico. Además existe una confusión en la literatura dental al respecto de los dientes diagnosticados con el "síndrome del diente fisurado" y aquellos fracturados como consecuencia de accidentes de procedimientos. Las fracturas de la última categoría han sido denominadas Fracturas Apicales Inducidas por Williams y fracturas radiculares verticales, por otros. Mientras que en ambos casos el la consecuencia en el diente puede ser la misma, la etiología es diferente. También es un hecho que mientras que la profesión dental se valga principalmente de las evaluaciones radiográficas, este síndrome no puede ser fácilmente identificado. Las fisuras se producen de mesial a distal, donde las películas radiográficas son incapaces de capturarlas. Por tanto, más y más dientes serán víctimas del "síndrome del diente fisurado". Aún así, si se detectan pueden ser salvados. Los dientes fisurados son muy difíciles de diagnosticar, especialmente si el dentista no los está buscando. En muchos casos, debido a la ignorancia por parte del dentista, el paciente es tildado de "paranoico", y es enviado a su casa con una prescripción de tranquilizantes. Es notable que en su estudio Cameron reportó que un paciente aquejado del síndrome del diente fisurado estaba siendo medicado con Tegretol debido a una posible neuralgia trigeminal y para otro se estaba considerando cirugía cerebral. Los dientes fisurados son un estadio intermedio de una serie de eventos que, si no se reconocen y no se tratan, culminarán con la extracción del diente. El diagnóstico y tratamiento precoces a menudo pueden prevenir molestias innecesarias y tratamientos más invasivos. Definición El "Síndrome del Diente Fisurado" se caracteriza por una fractura incompleta de un diente posterior con pulpa vital, la cual incluye dentina y posiblemente la pulpa dental. En un intento de expandir el dominio del síndrome, deben incluirse también en esta definición los dientes fisurados con necrosis pulpar y/o abscesos dentoalveolares. Un diente se considera "fisurado" cuando los potenciales segmentos de la fractura se mantienen intactos por una porción del diente a través del cual la fractura aún no se ha extendido. La "fisura" se refiere a una disrupción o interrupción de la continuidad de la
Drossmangastroenterology.comconstipation, associated emotional symptoms (anxiety, depression), For severe constipation, your doctor may prescribe Miralax, which your general medical health, possible side effects (SSRI's have is a Polyethylene Glycol Solution (PEG), similar to what was once fewer effects on the heart), and possibly your previous experience used prior to colonoscopies to thoroughly clear out the bowel. with other antidepressants. Finally it is important to remember that Miralax is modified so that it can be taken in small amounts on The Use of
these medications are being used within GI to treat functional GI a regular basis. Lubiprostone is also prescribed as a prescription symptoms, not emotional difficulties, and this occurs often in lower medication used to treat IBS-C or chronic constipation.
dosages than for treating major depression. Nevertheless even in Psychological treatments have also been used to reduce pain and low dosages it may help to reduce stress or symptoms of emotional distress often resulting from the chronic symptoms of IBS and other other GI symptoms. Your doctor can refer you to a specialist who can help you with these psychological treatments. Various techniques Treatment of
are used to improve management of symptoms, such as: Relaxation Therapy, Hypnosis, Cognitive-Behavioral Therapy Irritable Bowel
How long will you need to take
(CBT) which can be useful in understanding how specific thoughts may have a negative effect on managing an illness. Syndrome
This varies from person to person. Some IBS patients may only need and other Functional GI
to take an antidepressant for 6 months to a year. Others, especially Future Treatments
those with a longer history or more severe case of IBS, may need Disorders
to take them longer. This decision will depend on how the patient Newer medications that act at nerve receptors in the GI system responds to the antidepressants, and whether IBS symptoms recur may become available shortly. Drugs that can block pain from the Christine B. Dalton, PA-C when the medication is stopped or decreased. intestines are currently being studied, and some appear to be more Douglas A. Drossman, MD effective for diarrhea-predominant or constipation-predominant Other Treatments for IBS
IBS. As more information becomes available about these new First-line therapy for IBS is often lifestyle modification. Keeping medicines, we will communicate this information to you. a diary of foods, situations and emotions that may trigger IBS symptoms can be helpful. You and your physician can develop The UNC Center for Functional GI
strategies to help manage your symptoms. These can include helpful & Motility Disorders
dietary changes, such as eating small, more frequent meals; avoiding high fat foods; increasing or decreasing fiber; and eliminating other What are functional GI disorders? problematic foods.
For further information about IBS and other functional GI and motility disorders, please visit our website at There are more than twenty functional disorders of the GI tract. Medications that act directly on the GI tract can be used for specific Of these, IBS is the most common and most thoroughly studied. symptoms, such as antispasmodic medications, which are used to These disorders are characterized by abnormal changes in the treat abdominal cramping and pain. These include: Our website also provides information regarding opportunities to movement of the muscles of the intestines (abnormal motility), • Hyoscyamine (Levsin) participate in on-going research studies at UNC. an increase in the sensations produced by intestinal activity • Dicyclomine (Bentyl) (visceral hypersensitivity), and brain-gut dysfunction, especially • Alosetron (for diarrhea and IBS-D) difficulties in the brain's ability to regulate painful signals from the GI tract. With IBS, a person's awareness and interpretation Loperamide (Imodium) is a medication that slows gut motility, can be of these activities may be abnormal (abnormal perception). effective in treating diarrhea, and is available without a prescription. For more severe diarrhea in association with IBS, Alosetron may be Abnormal Motility
prescribed to help reduce diarrhea and pain. Instead of the normal muscular activity (motility) of digestion, IBS patients may experience spasms and cramping. If the motility For mild constipation, Milk of Magnesia is safe and effective for is too fast it may result in diarrhea, and if it is too slow it might patients and is available over the counter. It is important to avoid result in constipation. These two conditions may also produce stimulant laxatives, such as senna or cascara, since they may have abdominal discomfort or pain in IBS patients. Abnormal motility a negative effect on the bowel and can cause more problems with can also be associated with abdominal cramping, belching, cramping and pain. urgency, or other unpleasant GI symptoms. Visceral Hypersensitivity
impulses, a natural response. Much like treating diabetes with • Amitriptyline (Elavil) For IBS patients, there can also be increased sensitivity of the nerves the insulin that is missing, antidepressants may help recover the • Imipramine (Tofranil) in the GI tract. This can develop after a gastrointestinal infection or brain's ability to respond to pain signals properly. • Desipramine (Norpramin) an operation that causes injury to the nerves in the intestine. This • Nortriptyline (Pamelor) and others. results in a lower threshold for experiencing intestinal sensations, Certain antidepressants can also help regulate abnormal bowel leading to abdominal discomfort or pain. In those with visceral functions like diarrhea and, constipation, as well as other IBS The SSRI's have been available for a shorter period of time and hypersensitivity, the stretch put on the intestines from eating even symptoms. The tricyclic antidepressants (TCA's) help with can also be useful in treating IBS along with associated symptoms, small amounts of food may produce discomfort. diarrhea and the serotonin reuptake inhibitors (SSRI's) help such as depression or anxiety, though may not be as helpful as treat constipation. Furthermore, these medicines can help with the other classes of medications for pain. SSRI's include: Brain-Gut Dysfunction
other problems such as anxiety and depression, which are often When the nerve impulses from the gut reach the brain, they may be • Citalopram (Celexa) associated with chronic painful disorders. Finally, a recent experienced as more severe or less severe based on the regulatory • Escitalopram (Lexapro) observation relates to growing knowledge that antidepressants activities of the brain-gut axis. Signals of pain or discomfort travel • Paroxetine (Paxil) may also stimulate nerve cell growth and possibly restore more from the intestines up to the brain. The brain has the ability to "turn • Sertraline (Zoloft) normal nerve functioning in the brain and intestines over time. down" the pain by sending signals that block the nerve impulses • Fluoxetine (Prozac) This is why at our Center we might recommend treatment for a produced in the GI tract. Recent studies, including brain imaging year or two before tapering off the medication.
Common side effects of SSRI's may include nervousness, vivid research at our Center, have shown that this ability to turn down dreams, sleep disturbances, sexual difficulties, and/or diarrhea. the pain is impaired in patients with IBS. In addition, the pain can become more severe when an individual is experiencing When are antidepressants used for IBS?
The SNRI's are a relatively new class of medications that are psychological distress. Often this may occur because of stresses effective in treating pain like the TCA's but without the side Patients with mild IBS symptoms do not usually need in life or even the stress and frustration of the GI symptoms. This effects of TCA's. SNRI's include: antidepressants. Their symptoms may be controlled by other brain-gut dysfunction can be remedied with either psychological treatments. Patients with moderate or severe IBS may benefit from • Venlafaxine (Effexor) treatments or antidepressants or a combination of both. taking an antidepressant medication either alone or in combination • Duloxetine (Cymbalta • Desvenlavaxine (Pristiq) Why are antidepressants used to treat IBS?
with other treatments. The full effects of antidepressants typically take four to six weeks to occur. Usually, low dosages are used at • Milnacipram (Savella) Some medicines can have more than one action in treating medical the onset and gradually increased as needed. In some cases the Duloxetine has been marketed not only for depression but problems. For example, aspirin can be used to treat headaches, muscle low dose is sufficient to improve symptoms. for treating peripheral neuropathy, fibromyalgia and other aches and fever, but it can also help prevent heart attacks. Although types of pain. Preliminary studies suggest it is helpful for antidepressants were developed to treat depression, research studies Which antidepressants are used for IBS
visceral (i.e., bowel) pain, as well. Common side effects include have shown that they can also be effective as analgesics (drugs that and what are their possible side effects?
nausea, headache and, rarely, changes in liver chemistry tests. reduce pain). Antidepressants are, therefore, used to treat such chronic Milnacipran is an SNRI that is actually marketed for treatment of painful conditions as migraine headaches, diabetic neuropathy and Traditionally, the most frequently prescribed antidepressants fell pain (fibromyalgia) but not as an antidepressant.
fibromyalgia. Similarly, antidepressants are effective in treating into one of two large groups --Tricyclics (TCA's) and Selective symptoms of IBS and other functional GI disorders. Patients who Serotonin Reuptake Inhibitors (SSRI's). More recently, a newer Other types of antidepressants that may be used to treat IBS are: have taken antidepressants for their IBS symptoms have reported group, Serotonin-Norepinephrine Reuptake Inhibitors (SNRI's), • Bupropion (Wellbutrin) significant improvement in their abdominal pain and reduction in has also been shown to be effective in treating these disorders. • Mirtazipine (Remeron) other IBS symptoms, such as diarrhea, constipation, bloating, nausea • Trazodone (Desyrel) When first taking antidepressants, some people may notice some side effects, but these usually go away in a few days or weeks What are common concerns about
How do antidepressants work in IBS?
as the body gets used to the medicine. Common side effects of taking antidepressants?
TCA's are dry mouth or, at times, difficulty sleeping, difficulty The brain is always monitoring and processing all that goes on in the urinating, sexual difficulties, constipation, dizziness and/or Some people are concerned that these medications are addicting, body. As already noted, antidepressants are known to work at the or they may alter mental functioning. They are not addictive and level of the brain and spinal cord to block pain messages between the do not change your personality or your thinking. Your physician GI tract and the brain, thereby reducing visceral hypersensitivity. In TCA's have been on the market for many years, are relatively will choose a particular antidepressant based on a combination effect, there is recovery of more normal brain-gut function, possibly inexpensive, and have been used more frequently in treating of factors including your major IBS symptoms of diarrhea or by helping the brain send down signals to block incoming pain functional GI disorders. TCA's include:
Que mediante la Resolución No. 852002 del 19 de junio de 2002, el Consejo Arancelario y Aduanero Que conforme los artículos 38, 39 y 55 del Protocolo al Tratado General de Integración Económica Centroamericana Protocolo de Guatemala, modificado por la Enmienda del 27 de febrero de 2002, el Consejo de Ministros de Integración Económica (COMIECO), tiene bajo su competencia los asuntos de la Integración Económica Centroamericana y como tal, le corresponde aprobar los actos administrativos del Subsistema Económico;