Pleomorphic adenoma of oral minor salivary glands: An investigation of its neoplastic potential based on apoptosis, mucosecretory activity and cellular proliferation

OBJECTIVE

The aim of this study was to investigate the neoplastic potential of the PA of minor oral salivary glands measured by apoptosis (Bcl-2, Bax and p53), mucosecretory activity (MUC1), and cellular proliferation (Ki-67).

DESIGN

Thirty-one cases of PA of the oral cavity and four controls (C) taken from normal oral minor salivary glands were analyzed using the immunohistochemistry technique. The proteins were detected utilizing a semi-quantitative method (scores) as follows: (-) negative ≤5%, (+) low 6-25%, (++) moderate 26-50% and (+++) high >50% of positive tumour cells. The apoptotic indices were evaluated by the ratio Bcl-2/Bax. Non-parametric comparison and correlation tests were used for analysis.

RESULTS

The data showed high staining of anti-apoptotic protein Bcl-2 in both groups (PA=57.9%; C=67.7%) and a significantly lower expression of pro-apoptotic protein Bax (PA=22.7%; C=97.7%) and MUC1 (PA=14%; C=82.3%) in PA than in C (p<0.001). On the other hand, a similar expression of Ki-67 and p53 proteins (≤5%) was seen in both PA and C. In PA, only 2/31 cases showed the ratio Bcl-2/Bax<1.There was no difference in cellular expression with regard to clinical variables or clinical outcome (p>0.05).

CONCLUSION

The neoplastic potential of PA could be associated with an imbalance in apoptotic processes and a lower index of cellular proliferation. Mucosecretory activity does not play a significant role in primary PA.

Atypical esthesioneuroblastoma invading oral cavity: a case report and review of the literature

Esthesioneuroblastoma is an uncommon tumour of neuroectodermal origin. The authors describe a rare presentation of an atypical esthesioneuroblastoma invading oral cavity. The clinical presentation, aetiology, diagnosis, and management of this condition are discussed. The patient developed significant swelling in the right anterosuperior alveolar mucosa and had moderate tooth mobility. Conventional x-rays and computed tomography revealed a large osteolytic lesion, with imprecise limits. Histological findings along with immunohistochemical staining results and clinical features led to the diagnosis of high-grade esthesioneuroblastoma. Local recurrences and neck metastasis were detected. The rare oral findings produced delayed in diagnosis which may lead to a compromise in planning and execution of further radical management and thus a poor prognosis.

A 12-year retrospective survey of management of patients with malignant neoplasms in the orbital cavity in a brazilian cancer hospital

Purpose:

The aim of this study was to investigate the distribution of different types of malignant tumors in the orbital cavity, surgical treatments, and subsequent prosthetic rehabilitation.

Materials and Methods:

A retrospective sample of 269 charts of patients attending a public reference cancer hospital in Goiania, Goias, Brazil, between 1998 and 2009 was selected. Study variables included demographic data, clinical and histopathological features, and patient rehabilitation. Frequency analysis, chi-square test and multiple logistic regression were used for data analysis.

Results:

Patients’ age ranged from 1 to 92 years and 50.2% were female. The most prevalent tumors were basal cell carcinoma (58%), retinoblastoma (17.1%), squamous cell carcinoma of the conjunctiva (7.1%), malignant melanoma (6.7%), and rhabdomyosarcoma (4.5%). Surgical treatment was performed in 250 patients (92.3%), but only 29 patients (10.8%) received ocular prosthetic rehabilitation. Lower age (p<0.001) and enucleation surgery (p<0.001) were significantly associated with prosthetic rehabilitation.

Conclusions:

Results revealed high occurrence of mutilating interventions and low provision of prosthetic care, limited to younger patients who had undergone enucleation surgery. The high unmet demand for rehabilitation emphasizes the need to incorporate appropriate care for ocular and orbital deformities into the Brazilian public health system.

A qualitative study of the dimensions of patients' perceptions of facial disfigurement after head and neck cancer surgery

The study aim was to explore the underlying dimensions of patients' perceptions and experiences of facial disfigurement following surgery for cancer treatment, using a qualitative approach based on individual in-depth interviews. Data analysis and interpretation consisted of separating responses into phrases or statements with a single thematic aspect. Subsequently, a number of dimensions and categories were created using a deductive-inductive content analysis. Three main categories emerged: discovering of the cancer, coping with the disease and disfigurement, and reconstructing a new identity. The initial stage elicited feelings of fear, denial, and guilt as a reaction to the stigma and prejudice. Coping strategies included resignation and acceptance, deepening religiosity, reinforcement of familiar cohesion, and creation of a social network of solidarity and support. The final stage comprised incorporation of the altered facial image, rehabilitation possibilities, reconstruction of personality and self-image, and the feeling of having overcome the disease. It was concluded that individual experiences are complex, challenging, and have striking effects on their lives. There is an urgent need for training and improvement in human resources to manage these patients in a multidisciplinary approach, aimed at their reintegration into society and reducing the prejudice and stigma of the disease and disfiguration.

The expression of chemokines CCL19, CCL21 and their receptor CCR7 in oral squamous cell carcinoma and its relevance to cervical lymph node metastasis

The purpose of this study is to determine the expression of CCL19, CCL21, and CCR7 in samples of oral squamous cell carcinoma (OSCC) and their relationship with clinical and microscopic parameters. A comparative analysis was made of the mRNA expression of these chemokines and receptor in OSCC and normal oral mucosa. The immunoexpression of CCR7, CCL19, and CCL21 was also verified in OSCC and lymph nodes. Statistical significance was accepted at P < 0.05. Similar levels of CCR7, CCL19, and CCL21 mRNA in OSCC and normal oral mucosa were seen. A low expression of CCL19 and CCL21 in the intra- and peritumoral regions was observed. Scarce CCL19(+) and CCL21(+) cells were also noted in metastatic and non-metastatic lymph nodes. No association was found between the expression of these chemokines and clinical and microscopic parameters. Our findings would suggest that CCL19 and CCL21 may not be associated with cervical lymph node metastasis or other clinical and microscopic factors in OSCC.

Promoter hypermethylation in primary squamous cell carcinoma of the oral cavity and oropharynx: a study of a Brazilian cohort

Epigenetic silencing of cancer-related genes plays an important role in oral/oropharyngeal squamous cell carcinoma (OSCC). We evaluated promoter hypermethylation of 4 cancer-related genes in OSCCs of a Brazilian cohort and determined its relationship with exposure to alcohol, tobacco, HPV infection and clinicopathological parameters. CDKN2A (cyclin-dependent kinase inhibitor 2A or p16), SFN (stratifin or 14-3-3 σ), EDNRB (endothelin receptor B) and RUNX3 (runt-related transcript factor-3) had their methylation patterns evaluated by MSP analysis in OSCC tumors (n = 45). HPV detection was carried out by PCR/RFLP. Aberrant methylation was detected in 44/45 (97.8 %) OSCC; 24.4 % at CDKN2A, 77.8 % at EDNRB, 17.8 % at RUNX3 and 97.8 % at SFN gene. There was no significant association between methylation patterns and clinical parameters. HPV (subtype 16) was detected in 3 out of 45 patients (6 %). Our findings indicate that HPV infection is uncommon and methylation is frequent in Brazilian OSCCs, however, EDNRB and SFN gene methylation are not suitable OSCC biomarkers due to indistinct methylation in tumoral and normal samples. In contrast, CDKN2A and RUNX3 genes could be considered differentially methylated genes and potential tumor markers in OSCCs.

Occurrence of maxillary sinus abnormalities detected by cone beam CT in asymptomatic patients

Background

Although cone beam computed tomography (CBCT) images of the maxillofacial region allow the inspection of the entire volume of the maxillary sinus (MS), identifying anatomic variations and abnormalities in the image volume, this is frequently neglected by oral radiologists when interpreting images of areas at a distance from the dentoalveolar region, such as the full anatomical aspect of the MS. The aim of this study was to investigate maxillary sinus abnormalities in asymptomatic patients by using CBCT.

Methods

1113 CBCT were evaluated by two examiners and identification of abnormalities, the presence of periapical lesions and proximity to the lower sinus wall were recorded. Data were analyzed using descriptive statistics, chi-square tests and Kappa statistics.

Results

Abnormalities were diagnosed in 68.2% of cases (kappa = 0.83). There was a significant difference between genders (p < 0.001) and there was no difference in age groups. Mucosal thickening was the most prevalent abnormality (66%), followed by retention cysts (10.1%) and opacification (7.8%). No association was observed between the proximity of periapical lesions and the presence and type of inflammatory abnormalities (p = 0.124).

Conclusions

Abnormalities in maxillary sinus emphasizes how important it is for the dentomaxillofacial radiologist to undertake an interpretation of the whole volume of CBCT images.

Angiogenesis and lymphangiogenesis in mucoepidermoid carcinoma of minor salivary glands

BACKGROUND

Mucoepidermoid carcinoma is the most common malignant tumor of salivary glands. This tumor is characterized by a great variability in clinical behavior, and little is known about the pathological mechanisms involved in its variance. Angiogenesis is an important step in tumor progression and is believed to be an essential event for metastatic dissemination.

METHODS

We aimed to investigate angiogenesis and lymphangiogenesis in mucoepidermoid carcinoma measuring the density of neoformed and lymphatic vessels using CD105 and D2-40 antibodies, respectively, and by immunohistochemical evaluation of VEGF-A and VEGF-C proteins. It was also investigated the expression of D2-40 in neoplastic cells.

RESULTS

We studied 26 cases of mucoepidermoid carcinoma, which showed great angiogenic activity measured by neoformed vessel density. However, a low density of lymphatics was observed. VEGF-A, VEGF-C, and D2-40 were commonly detected in mucoepidermoid carcinoma, but only VEGF-A expression correlated with neoformed vessel density. Recurrence and nodal metastasis were associated with low VEGF-A expression and low neoformed vessel density, indicating that impaired angiogenesis could lead to an aggressive phenotype.

CONCLUSIONS

Angiogenesis seems important in the modulation of mucoepidermoid carcinoma pathogenesis; however, none of the parameters analyzed could predict tumor behavior.

Nonlipidized juvenile xanthogranuloma: an unusual variant with a potential diagnostic pitfall

Juvenile xanthogranuloma (JXG) is a histiocytic inflammatory disorder that can present different histologic patterns. Classic JXG consists of sheets of foamy histiocytes and numerous multinucleated Touton giant cells. Nonlipidized JXG (NJXG) is one of the unusual variants of JXG, consisting of a diffuse monomorphic infiltrate of mononuclear histiocytes, suggesting an aggressive or malignant tumor due the high mitotic index. However, NJXG behaves clinically as classic JXG. We present an unusual case of a 6-year-old boy who presented an exophytic ulcerated nodule on the lower lip diagnosed as NJXG. The boy is currently well without recurrence three years after surgical excision.

Digital subtraction radiography evaluation of longitudinal bone density changes around immediate loading implants: a pilot study

OBJECTIVE

The aim of this study was to assess longitudinal quantitative changes in bone density around different implant loading protocols and implant surfaces measured by digital subtraction radiography (DSR).

METHODS

12 patients received bilateral homologous standard and TiUnite® (Nobel Biocare, Kloten, Switzerland) single-tooth implants under 2 implant-loading protocols: immediate loading (8 patients, 16 implants, 12 maxillary) and conventional loading (4 patients, 8 implants, 4 maxillary). Standardized periapical radiographs were taken immediately after implant placement (baseline image) and at the 3-month, 6-month and 12-month follow ups. Radiographic images were digitized and submitted to digital subtraction using the DSR system® (Electro Medical System, Nyon, Switzerland), resulting in three subtracted images. Quantitative analysis of bone density was performed using Image Tool® software (University of Texas Health Science Centre, San Antonio, TX) to assess pixel value changes in five areas around the implants (crestal, subcrestal, medial third, apical-lateral and apical).

RESULTS

Repeated-measures analysis of variance showed that grey levels were significantly influenced by follow-up time and implant-loading protocol. A linear increase in grey levels was found for immediate loading (IML) implants and a significant decrease in grey levels was observed in the 12-month follow up for conventional loading implants. No effect of implant surface treatment was observed.

CONCLUSION

In conclusion, IML protocol induced mineral bone gain around single-tooth implants after the first year under function for cases with favourable bone conditions.

Effect of intraoral low-level laser therapy on quality of life of patients with head and neck cancer undergoing radiotherapy

BACKGROUND

Low-level laser therapy has been used to reduce complications of head and neck cancer treatment. The aim was to assess the impact of laser in the quality of life (QOL) of patients receiving radiotherapy.

METHODS

Sixty outpatients were randomly assigned into 2 groups. The laser group received applications and the placebo group received sham laser. QOL was assessed using the University of Washington QOL questionnaire. A repeated-measures analysis of variance (ANOVA) was used for comparisons of overall QOL scores and Mann-Whitney test compared changes in domain scores.

RESULTS

A decrease in QOL scores was observed in both groups and the reduction in the laser group was significantly lower (p < .01). Changes in QOL scores regarding pain, chewing, and saliva domains were evident in the placebo group. Both health-related QOL and overall QOL were rated higher by patients who received laser therapy.

CONCLUSION

Laser therapy reduces the impact of radiotherapy on the QOL of patients with head and neck cancer.

Differential diagnosis of apical periodontitis and nasopalatine duct cyst

INTRODUCTION

An accurate differential diagnosis of apical periodontitis (AP) and nasopalatine duct cyst (NPDC) should be established to define the best treatment for endodontically treated maxillary anterior teeth with apical periodontitis. Three-dimensional cone beam computed tomography (CBCT) images help to plan treatment and to define an initial diagnostic hypothesis. However, endodontic treatment or retreatment may be unnecessarily prescribed when radiographs show a superimposition of the incisor foramen over the apex of maxillary central incisors, mimicking AP. Diseases of nonendodontic origin that affect the tooth apex, such as NPDC, should be included in the differential diagnosis.

METHODS AND RESULTS

Four clinical cases of patients with large periapical radiolucencies and similar radiographic features are described. AP is usually a consequence of endodontic infection; in cases of NPDC, however, spontaneous epithelial proliferation, in addition to bacterial infection and trauma, may also contribute to cyst formation. The frequency and recurrence rates of NPDC are low, and its behavior is less aggressive. Surgical enucleation of the periapical lesion is recommended after nonsurgical treatment does not heal AP.

CONCLUSIONS

The use of new diagnostic tools, such as CBCT imaging, may provide detailed high-resolution images of oral structures, which help to make an initial diagnostic hypothesis and to plan surgery. Histopathology is mandatory for the differential diagnosis.

Oral squamous cell carcinoma versus oral verrucous carcinoma: an approach to cellular proliferation and negative relation to human papillomavirus (HPV)

Human papillomavirus (HPV) has been cited as a possible initiating agent in the pathogenesis of oral cancer. However, the literature tends to be both controversial and inconclusive about the prevalence of HPV and its potential for proliferation in oral squamous cell carcinoma (SCC). The aim of this study was to investigate the cellular proliferation and the presence of HPV in SCC and verrucous carcinoma (VC). Forty-seven samples of SCC were selected and divided into three groups: 39 SCC, 8 VC, and 9 of normal mucosa (control-CT). Quantitative analyses of all groups showed a greater expression of PCNA, followed by Ki-67 and cyclin B1. A significant difference was observed in cyclin B1 expression in the SCC group compared with VC. PCNA, Ki-67, and cyclin B1 were statistically significant when comparing the SCC and CT groups. However, when SCC and VC were compared, there was no difference in Ki-67 expression. Our results showed that only cyclin B1 had an association with histological grade, and that poorly differentiated tumors presented a higher expression of cyclin B1. Therefore, considerable differences in the cellular proliferation between SCC and VC were observed, and no correlation with HPV was established, since all samples were negative for HPV.

Implant-supported obturator overdenture for extensive maxillary resection patient: a clinical report

This clinical report presents an implant-retained obturator overdenture solution for a Prosthodontic Diagnostic Index Class IV maxillectomy patient with a large oronasal communication and severe facial asymmetry, loss of upper lip and midfacial support, severe impairment of mastication, deglutition, phonetics, and speech intelligibility. Due to insufficient bone support to provide satisfactory zygomaticus implant anchorage, conventional implants were placed in the body of the left zygomatic arch and in the right maxillary tuberosity. Using a modified impression technique, a cobalt-chromium alloy framework with three overdenture attachments was constructed to retain a complete maxillary obturator. Patient-reported functional and quality of life measure outcomes were dramatically improved after treatment and at the two-year follow-up.

Chondrosarcoma of the temporomandibular joint: a case report in a child

This article reports a rare case of a temporomandibular joint (TMJ) chondrosarcoma in a child. Chondrosarcoma is a malignant cartilaginous neoplasm that resembles synovial chondromatosis. In the head and neck region, chondrosarcoma is uncommon, corresponding to 6.4% to 12% of all reported cases. The majority of patients with chondrosarcoma are in the third to fourth decades of life. A Pubmed search showed that 20 TMJ chondrosarcoma cases had been reported up to 2008. The present case was of an 11-year-old girl referred to an Oral Disease Center and presenting with a preauricular swelling on the right side and normal ENT evaluation. The patient was healthy. Discrete pain and mild limitation of mouth opening were observed. A panoramic radiograph as well as computed tomography (CT), ultrasound, and magnetic resonance imaging (MRI) revealed an osteolytic lesion in the right TMJ. The skull base and adjacent spaces were preserved but adjacent anatomic structures were displaced. After an incisional biopsy, the patient underwent high condylectomy. Microscopic findings showed a tumor exhibiting cartilaginous tissue proliferation with cellular pleomorphism, nuclear hyperchromasia, and mixoid changes in the matrix. The immunohistochemical analysis of the expression of Ki-67 and Cyclin B1 proteins (cellular proliferation markers) revealed a very low proliferative cell index. The 3.5 years of clinical and imaging follow-up have shown no evidence of recurrence or metastasis, but signs of myofascial disorders could be observed. It is concluded that cartilaginous lesions in the jaws must be regarded with suspicion, since benign and malignant lesions may show similar clinical features. This case emphasized the importance of interdisciplinary approaches to minimize the possibility of misdiagnosis.

Low-grade gingival leiomyosarcoma in a child

Leiomyosarcoma (LMS) of the oral cavity, a rare mesenchymal tumor exhibiting smooth-muscle differentiation, is extremely uncommon in childhood. The most frequent location of childhood LMS is the gastrointestinal tract, particularly the stomach. The purpose of this paper is to report a case of leiomyosarcoma affecting the gingival tissues and mandible of a 9-year-old girl with peculiar clinical, microscopic, and radiographic features. Clinical and radiographical examinations revealed a gingival growth affecting the primary mandibular right first molar with inflammatory features. The lesion was initially suspected to be pyogenic granuloma and was removed by excisional biopsy. Microscopic findings showed a hypercellular proliferation of mesenchymal spindle cells, suggesting malignant spindle cell neoplasm. Immunohistochemical, histochemical, and radiographic studies were undertaken, and the final diagnosis established was a low-grade leiomyosarcoma in the gingiva.

Dual role of CCL3/CCR1 in oral squamous cell carcinoma: implications in tumor metastasis and local host defense

Chemokines are small chemotactic cytokines that can induce the migration of leukocytes, activate inflammatory/immune responses and have recently been implicated in the regulation of tumor growth and organ-specific spread. In this setting, the macrophage inflammatory protein-1alpha (CCL3) chemokine displays a diversity of roles that may contribute to the directional migration of squamous cells into cervical lymph nodes or to the defense against tumor initiation and progression. Thus, the aim of this study was to determine, for the first time, the expression of CCL3 and their receptors, CCR1 and CCR5, by real-time polymerase chain reaction in samples obtained from oral squamous cell carcinoma (OSCC) and healthy gingival tissue (control). In addition, we investigated the immunoexpression of these molecules in neoplastic cells (parenchyma), inflammatory/immune cells (stroma) in primary OSCC and in metastatic and non-metastatic lymph node tissues. The relationship of CCL3/CCR1 with survival data was also evaluated. The analysis of mRNA expression revealed a significantly higher expression of CCL3 and CCR1 in OSCC compared with the controls (P<0.05). The expression of CCR5 was not different in the two groups. The percentages of CCL3+ and CCR1+ cells were observed to be similar in parenchyma and stroma in the OSCC without lymph node metastasis when compared with OSCC with lymph node metastasis (P>0.05). However, we observed the density of CCL3+ nodal cells to be significantly higher in metastatic lymph nodes when compared with non-metastatic lymph nodes in the same patients (P<0.05). Considering CCL3 in stroma, the mean survival rate for patients with high CCL3+ cell percentage was better than for those with low CCL3+ cell percentage. Our findings suggest that the CCL3/CCR1 axis may have a role in the spread of tumoral cells to the lymph nodes and also in the local host defense against the tumor.

Epithelial inclusion cyst after free gingival graft: a case report

There have been few case reports of cystic lesions occurring after gingival grafting. There are three reports of this type of sequela after connective tissue grafting, but this is the first known case of a cystlike lesion developing secondarily to a free gingival graft procedure. The bulky tissue, which had developed under the previously grafted area, was properly excised under local anesthesia. The small specimen removed was sent for histologic analysis. A new gingival graft was performed immediately after the lesion enucleation, as the cystic lesion had dislocated the earlier graft. The surgical wound healed uneventfully, and no recurrence was seen 18 months later The microscopic sections showed a cystic cavity lined with an orthokeratinized, hyperplastic, stratified squamous epithelium covered with fibrous connective tissue. The development of a cystlike lesion following a free gingival graft is, to date, an unpublished event. The fact that most cystic lesions appear in the mandibular lateral incisor-canine-first premolar area deserves further consideration.

Unicystic ameloblastoma in a child: a differential diagnosis from the dentigerous cyst and the inflammatory follicular cyst

Unicystic ameloblastoma (UA) is a benign epithelial odontogenic tumor of the jaws with an aggressive potential that commonly occurs in children. This cystic odontogenic neoplasm is generally asymptomatic and found during routine radiographs. The purposes of this report were to describe a case of UA involving the crown of the unerupted right mandibular second premolar in an 11-year-old girl under orthodontic treatment, and discuss its diagnosis and radiographic and microscopic findings, emphasizing its distinction from the dentigerous cyst and the inflammatory follicular cyst.

Low-grade central osteosarcoma of the mandible: a case study report

Low-grade central osteosarcoma is a rare type of osteosarcoma with peculiar clinical radiographic and microscopic features. The aim of this article is to report and discuss a case of low-grade central osteosarcoma in the mandible of a 42-year-old woman. The patient reported sensing mild pain and tooth mobility for a period of 4 years, despite continuous dental treatment. Radiographic evaluation showed a mixed radiopaque/radiolucenct lesion in the body, ramus, coronoid process, and condyle of the left side of the mandible. Destruction of the mandibular cortex in the area was also observed. After incisional biopsy, the patient underwent hemimandibulectomy. Microscopic findings showed a tumor exhibiting spindle cells with nuclear hyperchromasia and no mitotic activity, irregular osteoid formation, and soft tissue infiltration. The immunohistochemical analysis of the expression of Ki-67, Cyclin B1, and PCNA proteins (cellular proliferation markers) revealed a very low Ki-67+ and Cyclin B1+ cell index (mean 7% and 3%, respectively), but a moderate number of PCNA+ cells (mean 49%). The 2 years of clinical and imaging postoperative follow-up showed no evidence of recurrence. Clinicians should be aware of these lesions, because histopathologicially low-grade central osteosarcoma may be misinterpreted as fibrous dysplasia.

Lichen sclerosus et atrophicus of the oral mucosa

Lichen sclerosus et atrophicus (LSA) is a chronic, benign, depigmenting disease of the skin and mucous membranes most frequently affecting the female genitalia. Involvement of the oral mucosa without concurrent genital or skin lesions has been reported only occasionally in the literature. In view of the rarity of reported cases, one lesion affecting only the labial mucocutaneous area is presented along with a description of the disease's clinical and histopathological findings.

[Reliability of the declaration of underlying cause of infant deaths in the metropolitan region of southeastern Brazil]

The quality of official information on underlying causes of infant deaths was studied on the basis of data collected for a population-based study of the surveillance of infant mortality in the metropolitan region of Belo Horizonte, Brazil in 1989. The survey included the analysis of a sample of infant deaths carried out by comparing the underlying causes of death as coded on death certificates to those recorded by a group of doctors who abstracted information from hospital records. We verified that 11.7% of neonatal deaths did not have the underlying cause of death confirmed by the investigation (kappa = 0.61), and neither did 44.0% of post-neonatal deaths (kappa = 0.47). It is believed that this major disagreement among post-neonatal deaths is due to the close correlation observed among the major causes of death within this group (pneumonia, diarrhoea and malnutrition). For example, associated malnutrition was observed in 76.9% of those cases in which diarrhoea was coded as the underlying cause of death. It was concluded that the quality of the death certificates is not satisfactory. However, the composition of the main groups of causes presented no significant alteration after investigation and may be used in public health surveillance, especially if we regard pneumonia, diarrhoea and malnutrition as a group with the same determinants. Unfortunately, this group still accounts for a great number of otherwise avoidable deaths in Brazil.