Taurodontism in patients with nonsyndromic cleft lip and palate in a Brazilian population: a case control evaluation with panoramic radiographs

Root Curvature in Non-Syndromic Oral Clefts: A Case-Control Study in a Brazilian Population

OBJECTIVE

This study assesses the degree of root curvature in patients with non-syndromic cleft lip and/or palate (NSCL/P).

DESIGN

Retrospective. Case-control study.

SETTING

Root curvature was assessed in lower premolars and molars in 800 panoramic radiographs: 400 from patients with cleft and 400 from healthy control individuals. Root curvature was classified according to its angulation, as well as its apical, medial, or coronal localization.

RESULTS

The frequency of mild curvature in the NSCL/P group compared to the control group was higher in premolars especially in the left second premolar in cleft palate (OR: 6.91; 95% CI: 3.23-14.77; P < .0001). The frequency of moderate curvature in molars was significantly higher in the cleft group, with the highest risk in the right first molar in the cleft lip group (OR: 2.74; 95% CI: 1.67-4.52; P < .0001). Inclination was more frequently observed in the apical third of the root in the group with cleft, whereas for the control group, the curvature was more frequent in the medial third. In patients with cleft, the OR of curvature in the apical third was significant in premolars (left lower second premolar: Cleft lip, OR: 1.91; 95% CI: 1.04-3.52; P = .03; right lower second premolar: Cleft lip, OR: 1.91, 95% CI: 1.04-3.50; P = .03, cleft lip and palate, OR: 1.75; 95% CI: 1.12-2.73; P = .01).

CONCLUSION

The results of the current study indicate differences in root curvature in patients with non-syndromic cleft lip and/or palate, which should be considered during the dental treatment planning of patients.

Co-Occurrence of Taurodontism in Nonsyndromic Cleft Lip and Palate Patients in Subset of Indian Population: A Case-Control Study Using CBCT

The present study aimed to assess the co-occurrence of taurodontism in nonsyndromic cleft lip and palate (NSCLP) patients in a subset of Indian population using cone beam computed tomography (CBCT).

The study was a retrospective case-control kinds assessing 1500 CBCT scans over a period of 2 years; 67 scans out of 1500 showed cleft lip and palate (CLP). After fulfilling the inclusion and exclusion criteria, 38 subjects out of 67 comprised the case group; 80 randomly selected subjects constituted the control group. The first and second permanent molars in both the arches (8 teeth) of each subject were assessed for the presence and severity of taurodontism using the objective criteria. Statistical analysis was done using the χ2 test. Inter and intraobserver agreement was evaluated by Kappa statistics.

71.05% subjects showed taurodontism in case group, while 45% subjects showed its presence in control group; results being significant for both the groups. However, the comparison of number of teeth with taurodontism in the 2 groups came out to be statistically insignificant. Also no significant association of taurodontism was seen with gender or the different types of cleft (P = .437). Hypotaurodontism was the most prevalent type.

There was a higher prevalence of taurodontism in both groups which had been underestimated in the previous studies. This emphasizes the significance of the use of CBCT in detection of dental anomalies which would otherwise go undetected.

Maternal consumption of caffeine and second-hand tobacco smoke as risk factors for the development of oral clefts

OBJECTIVE

The aim of this case-control study was to investigate environmental factors, such as caffeine, folic acid, nutritional iron supplementation, multivitamin complexes, alcohol, and tobacco (second-hand smoking), which have been described as risk factors for the development of oral clefts.

METHODS

This case-control study employed convenience sampling and included 409 mothers: 132 with children with oral clefts (cases) and 277 with children without oral clefts (controls). The age range of the children in both groups was 0 to 2 years. A questionnaire was administered to each mother to inquire about their habits and food consumption during the first trimester of pregnancy.

RESULTS

Folic acid supplementation was observed in 116 (87.8%) of the case group (p < 0.001) and 271 (97.8%) of the control group. Regarding the use of ferrous sulfate, 114 (86.3%) of the case group and 271 (97.8%) of the control group reported using it. In the case group, 84 (63.6%) mothers reported being exposed to second-hand smoke, and 5 (3.7%) reported alcohol consumption (p = 0.797). In terms of caffeine consumption, 127 mothers (95.4%) in the case group consumed it (p = 0.13), while 247 (88.8%) reported consumption in the control group.

CONCLUSIONS

The results suggest a direct relationship between secondhand smoke, alcohol consumption, and the lack of maternal supplementation with oral clefts.

High prevalence of taurodontism in North China and its relevant factors: a retrospective cohort study

OBJECTIVE

The purpose of this study was to investigate the prevalence and relevant factors of taurodontism in North China.

METHODS

We retrospectively analysed the cone beam computed tomography (CBCT) of 1025 patients (496 male and 529 female) aged between 10 and 59 years. The crown-body/root (CB/R) ratios of the maxillary and mandibular molars were measured. The prevalence of hypotaurodontism, mesotaurodontism, and hypertaurodontism was then calculated and the incidence of taurodontism along with its relevant factors, was evaluated.

RESULTS

The overall rate of taurodontism in North China was as high as 78.9%. If the third molars (opsigenes) were excluded, which have a big morphological variation from each other, the rate was 52.4%. The mean CB/R ratio of taurodontism differs from tooth position: maxillary mandibular third molars > maxillary third molars > maxillary second molars > maxillary first molars > mandibular second molars > mandibular first molars (P < 0.05). In addition, the 1025 patients were divided into different age groups, and it was found that the mean CB/R ratio decreased with age (P < 0.05). Moreover, the CB/R ratio of the mandibular first and second molars in female patients was higher than males (P < 0.05).

CONCLUSION

This study revealed that taurodontism is widely prevalent in North China. The incidence of taurodontism increases the closer the tooth is to the back end of the dental arch, and quite a few of the maxillary and mandibular third molars teeth have tapered roots. And the taurodontism is decreased by age, as there were more affected female than male patients.

Tooth abnormalities associated with non-syndromic cleft lip and palate: systematic review and meta-analysis

OBJECTIVE

To evaluate the association between orofacial clefts (OFC) and tooth abnormalities (TA).

METHODS

We searched PubMed, Scopus, Web of Science, Cochrane Library, LILACS, and BBO, and in the gray literature and selected observational studies that evaluated the association between TA and OFC. The risk of bias was analyzed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed comparing the presence and absence of OFC, cleft type-cleft palate (CP) and cleft lip with or without palate (CL/P)-and cleft laterality-unilateral and bilateral. The certainty of evidence was evaluated using the GRADE approach.

RESULTS

A total of 99 studies were included in the qualitative analysis, and 37 were included in the meta-analysis. Only four studies were classified as low risk of bias. Significant associations were observed between the presence of OFC and tooth agenesis (OR = 19.46; 95%CI = 4.99-75.96), supernumerary teeth (OR = 4.04; 95%CI = 1.26-12.99), developmental defects of enamel (OR = 3.15; 95%CI = 1.28-7.80), microdontia (OR = 15.57; 95%CI = 1.06-228.51), and taurodontism (OR = 1.74; 95%CI = 1.74-2.86). Individuals with CP had a lower frequency of supernumerary teeth (OR = 0.22; 95%CI = 0.08-0.64), peg-shaped tooth (OR = 0.31; 95%CI = 0.12-0.80), and morphological TA (OR = 0.13; 95%CI = 0.04-0.45) than individuals with CL/P. No TA was significantly associated with cleft laterality (p > 0.05). The quality of the evidence was very low in all analyses.

CONCLUSION

Individuals with OFC had a higher frequency of TA than those without OFC. Individuals with CP had a lower frequency of TA than individuals with CL/P. No TA was associated to cleft laterality.

CLINICAL RELEVANCE

Help to identify the treatment needs of individuals affected by OFC, improving the services provided to this population.

Dental anomalies in non-syndromic orofacial clefts: a clinical approach

Orofacial clefts (OC) represent some of the most common congenital malformations and affect multiple structures in the craniofacial region. There are a wide range of morphological OC types within the spectrum of both non-syndromic OC (NSOC) and syndromic OC, including cleft lip (CL); cleft lip and palate (CLP) and cleft palate (CP). Here, we describe the most frequent dental anomalies seen in the permanent dentition of individuals with NSOC, comparing them between the three main cleft types (CL, CLP, CP). We present these findings from the perspective of prevalence relating to each anomaly, as well as the clinical characteristics and potential impact in the rehabilitation process. The investigation of dental anomalies associated with NSOC is important, helping to expand the phenotypic characterization of NSOC, improve initial diagnostics and establish appropriate rehabilitation and counseling.

Pulp enlargement in individuals born with cleft lip and palate pulp, a radiographic study from the cleft lip and palate service of paraiba, Brazil'

PURPOSE

Pulp chamber enlargement impacts endodontic treatment planning. The aim of this study was to evaluate alterations in pulp chamber size of posterior teeth in individuals born with cleft lip with or without cleft palate.

METHODS

Ninety individuals were treated at the Cleft Lip and Palate Service of the University Hospital Lauro Wanderley, Federal University of Paraíba, between the ages of 4 and 15 years born with cleft lip with or without cleft palate were selected. Ninety-nine patients from the archives of the residency program in Orthodontics of the Brazilian Dental Association (ABO) were paired by sex and age as a comparison group. Radiographs were evaluated by a single examiner, observing the presence/absence of an enlarged pulp chamber in the first and second permanent molars of all quadrants. Chi square or Fisher's exact tests were used (α = 0.05) in all comparisons.

RESULTS

Pulp enlargement was more frequently found among individuals born with cleft lip with or without cleft palate (p = 0.0005). However, pulp enlargement frequency was different among subjects born with clefts (p = 0.0006). Pulp enlargement was more common in the maxilla, in both groups. Individuals born with cleft lip with or without cleft palate more often had six or more teeth affected (p = 0.02). Furthermore, individuals with a bilateral cleft more often had six or more teeth affected in comparison to unilateral cases (p = 0.002).

CONCLUSION

Pulp enlargement is a frequent finding, particularly among individuals born with cleft lip with or without cleft palate, with a higher prevalence in the maxilla.

Taurodontism in the first permanent molars in Van der Woude syndrome compared to isolated cleft palate

OBJECTIVES

To analyse prevalence, pattern, and severity of taurodontism in individuals with Van der Woude syndrome (VWS) exhibiting cleft palate and compare with aged-matched non-syndromic cleft palate (NSCP) and non-cleft controls.

MATERIALS AND METHODS

One hundred and seventy-eight dental panoramic tomographs (DPTs) (105 girls and 73 boys) consisting of 42 VWS patients (x¯=8.55±1.02 years), 42 NSCP patients (x¯=8.59±1.02 years), and 94 normative non-cleft children (x¯=8.79±1.16 years) were assessed and their first permanent molars evaluated. Measurement 3 of the taurodontism index developed by Shifman and Chanannel with the Tulensalo modification was used. Prevalence, pattern, and severity were compared between groups. Statistical differences were determined by one-way analysis of variance and Fisher test. Repeatability was calculated by Cohens Kappa test.

RESULTS

The prevalence of taurodontic molars was 59.5% in VWS, 45.2% in NSCP, and 26.6% in non-cleft controls. The prevalence and severity of taurodontism in VWS and NSCP were significantly higher than in non-cleft children in all first permanent molars. There was no significant difference in prevalence and severity between VWS and NSCP. The odds for having taurodontism in the VWS group was approximately double compared to the NSCP group. Most of the taurodontic molars showed hypotaurodontism and taurodontism occurred bilaterally more frequently than unilaterally.

CONCLUSION

This study shows a higher prevalence of taurodontism in VWS and NSCP. Most taurodontic molars are hypotaurodontic and most occur bilaterally.

Association between Dental Anomalies and Orofacial Clefts: A Meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis to assess whether individuals with nonsyndromic orofacial clefts (OCs) display a higher frequency of dental anomalies (DAs) when compared with individuals without OCs.

METHODS

A literature search of indexed databases (PubMed, Cochrane, Web of Science, Embase, Scopus, and LILACS) was conducted without language restriction up to and including February 1, 2020. Cross-referencing was used to further identify articles. Several cleft teams across the United States and Europe were contacted to obtain unpublished data. The eligibility criteria were observational studies with original data that statistically compared individuals with OC without syndromes and those without OC on any type of DA in primary and/or permanent dentition. Random effects meta-analysis through the Mantel-Haenszel estimator was used to evaluate the association between OC and DA based on odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The literature search generated 933 records, and 75 full-text articles were reviewed. Twenty-six studies encompassing 15,213 individuals met the inclusion criteria. The meta-analysis revealed statistically significant associations between OC and agenesis (OR, 14.2; 95% CI, 9.4 to 21.3), supernumerary teeth (OR, 5.7; 95% CI, 3.3 to 9.7), developmental enamel defects (OR, 5.6; 95% CI, 3.5 to 9.0), microdontia (OR, 14.8; 95% CI, 4.0 to 54.6), peg-shaped anterior teeth (OR, 12.2; 95% CI, 3.6 to 41.2), taurodontism (OR, 1.7; 95% CI, 1.0 to 2.7), tooth malposition and/or transposition (OR, 5.6; 95% CI, 2.8 to 11.5), tooth rotation (OR, 3.2; 95% CI, 1.3 to 8.2), and tooth impaction (OR, 3.6; 95% CI, 1.1 to 12.2). The OR estimates of the reviewed studies exhibited significant heterogeneity (P < 0.0001). No association was observed between OC and fusion and/or gemination.

CONCLUSION

Within the limitations of this study, the available evidence suggests that individuals with OCs are more likely to present with a range of DAs than their unaffected peers.

KNOWLEDGE TRANSFER STATEMENT

The findings of the current review suggest that individuals with orofacial clefts (OCs) are more likely to present with a range of dental anomalies than their unaffected peers. Understanding the association between OCs and dental anomalies is essential in guiding clinicians during treatment-planning procedures and is important in raising our awareness of the possible need for future dental treatment for patients with OCs.

Patterns of dental anomalies in patients with nonsyndromic oral cleft

Aim: To characterize the patterns of dental anomalies (DA) in the mixed and permanent dentitions of patients with nonsyndromic oral cleft (NSOC). Methods: This cross-sectional, observational, case-control study included 173 patients, 61 with mixed dentition (NSOC=29 and control=32) and 112 with permanent dentition (NSOC=57 and control=55). All subjected were submitted to clinical and radiographic examination. Dental anomalies of eruption, number, size and shape outside the cleft area were considered. Results: Although there was no statistical significance among patients with mixed dentition, dental agenesis was the anomaly more common in this group. In patients with permanent dentition, a higher prevalence of DA in NSOC group compared to control group was observed (p=0.02). Gyroversion and dental agenesis were the DA more frequently observed in the permanent dentition and the second premolar was the tooth more affected (p=0.003). Mandible and the left side were more involved, and dental agenesis was more frequently found in patients with unilateral cleft lip with or without cleft palate (NSCL±P). Conclusion: Our findings show a higher frequency of DA in NSOCs than in the control group in patients with permanent dentition, mainly due to a higher occurrence of agenesis of second premolars in patients with unilateral NSCL±P.

Dental anomalies in the deciduous dentition of non-syndromic oral clefts patients

Abstract Objectives: to investigate the prevalence of dental anomalies in complete deciduous dentition of children with NSCL/P. Methods: this study included 75 children with NSCL/P and 286 healthy control. In both groups the children had deciduous dentition with ages varying from 4 to 6 years. Clinical examination, panoramic and periapical radiographies were performed and dental anomalies of number and shape were considered. Results: there was a higher prevalence of dental anomalies in the case group, compared to the control group. In all, 42 dental anomalies were identified, 25.33% in the case group and 8.04% in control group (p<0.001). Therewas a higher frequency of dental anomalies in NSCL/P (47.36%), followed by non-syndromic cleft lip (31.57%) and non-syndromic cleft palate (21.05%). The occurrence of agenesis (p= 0.005) and twinning (p = 0.029) were higher in the case group. Conclusions: the occurrence of agenesis and dental twinning was more frequent in the case group and may contribute to the definition of oral cleft subphenotype.

Dental abnormalities in individuals with pathogenic germline variation in DICER1

Pathogenic germline variation in the microRNA processing gene DICER1 gives rise to an autosomal dominant, tumor-predisposition disorder. Conditional deletion of Dicer1 in murine dental epithelium shows that it controls tooth patterning, size, number, and shape. The human dental phenotype of people with germline pathogenic variation in DICER1 is unknown. DICER1-carriers (n = 57) and family controls (n = 55) were evaluated at the NIH Clinical Center dental clinic as part of a comprehensive medical evaluation. Digital panoramic radiographs, bite-wing radiographs, and oral photographs were collected. A single observer, blind to DICER1 status, reviewed the dental records and determined the presence or absence of 11 dental characteristics as described in the clinic notes, radiographs, or oral photographs. Subjective phenotypes were reviewed on radiographs by two examiners (blind to DICER1 status) for the presence or absence of the dental characteristics to reduce inconsistencies. By simple association, bulbous crown, periodontitis, and taurodontism were all significant (p < .05). Logistic regression with chi-square maximum likelihood estimates showed that bulbous crown and periodontitis remained significant. Recognition of these phenotypes may aid identification of individuals and families at risk for DICER1-associated neoplasms. These findings may also guide dental care for individuals with germline DICER1 pathogenic variation.

Taurodontism

Taurodontism was hitherto considered to be a marker of oro-facial disorders. Since then, it has been reported with a moderately high-to-high prevalence on panoramic radiographs in case series of otherwise normal individuals in Brazilian, Middle Eastern and East Asian communities. This now understood higher than-formerly expected prevalence is important to the endodontist, orthodontist and restorative dentist. Therefore, the oral and maxillofacial radiologists should be aware of this phenomenon and its measurements to advise better their clinical colleagues.

Incidence of bifid uvula and its relationship to submucous cleft palate and a family history of oral cleft in the Brazilian population

Introduction

Bifid uvula is a frequently observed anomaly in the general population and can be regarded as a marker for submucous cleft palate.

Objective

In this study aimed to determine the frequency of bifid uvula and submucous cleft palate and their relationship with oral clefts in a Brazilian population.

Methods

We conducted a transversal, descriptive and quantitative study of 1206 children between August 2014 and December 2015. A clinical examination of the children was conducted by means of inspection of the oral cavity with the aid of a tongue depressor and directed light. After the clinical examination in children, parents answered a questionnaire with questions about basic demographic information and their family history of oral clefts in their first-degree relatives. After application of the questionnaires, the information collected was archived in a database and analyzed by the statistical program SPSS^® version 19.0, by applying Chi-Square tests. Values with p < 0.05 were considered statistically significant.

Results

Of the 1206 children included in this study, 608 (50.40%) were female and 598 (49.60%) were male (p = 0.773). The average age of children was 3.75 years (standard deviation ± 3.78 years). Of the 1206 children studied, 6 (0.5%) presented with bifid uvula. Submucosal cleft palate was not found in any child. When the family histories of children were examined for the presence of nonsyndromic cleft lip and/or cleft palate, no first degree relatives presented with the congenital anomaly.

Conclusion

This study revealed that the incidence of bifid uvula and submucous cleft palate in this population was quite similar to previously reported incidence rates. Our study suggests an intensification of new reviews, with broader and diverse populations, seeking to associate the occurrence of bifid uvula, submucous cleft palate and oral clefts.

Novel dental phenotype in non-syndromic Pierre Robin Sequence: A retrospective study

OBJECTIVE

The objective was to investigate dental phenotypes in individuals with non-syndromic Pierre Robin Sequence (ns-PRS) and compare the prevalence of these phenotypes with subjects with non-syndromic cleft palate (ns-CP) and a control group with subjects without any craniofacial anomalies.

METHODS

A total of 760 panoramic radiographs of 330 individuals (110 with ns-PRS; 110 with ns-CP and 110 without any malformations) were digitized and evaluated regarding the diagnosis of taurodontism, tooth agenesis, root dilaceration and tooth transposition. Chi-square test was applied to compare the occurrence of dental phenotypes between groups. A P value of less than 0.05 was considered statistically significant.

RESULTS

Total prevalence of dental phenotypes was 94.5% of ns-PRS; 54.5% of ns-CP and 59.1% of the control group subjects with a statistically significant difference for the ns-PRS when compared to the other two groups. Two dental phenotypes, taurodontism and dental agenesis were identified with statistically significant higher prevalences in subjects with ns-PRS when compared with the ns-CP group and the control group (p < 0.001). Taurodontism was the most prevalent dental phenotype, with 92.73% in the ns-PRS group, 40.91% for ns-CP and 44.55% in the control group. Tooth agenesis had a prevalence of 22.7% for ns-PRS, 4.5% for ns-CP and no case in the control group. For the prevalence of root dilaceration and tooth transposition, no statistically significant differences were observed between the three groups.

CONCLUSIONS

Due to the high frequency of taurodontism in individuals with ns-PRS, we suggested that this novel phenotype would be important in the phenotypic screening of ns-PRS and could be considered as a phenotype associated with ns-PRS.

Extending Coronectomy Indications to Third Molars with Taurodontism to Prevent Paresthesia and Mandible Fracture

Taurodontism is considered a dental anomaly responsible for a morphoanatomical change in the shape of the tooth in which the roots are reduced in size but the body of the tooth is enlarged and bulky. The aim of this paper is to present a case of a 25-year-old female patient with taurodontism of mandibular partially erupted third molars, presenting a high risk of angle fracture and paresthesia in case of their removal, treated by means of coronectomy. The postoperative period was uneventful and the patient remained in follow-up for 12 months. In conclusion, the identification of third molars with higher risk of complications related to their extractions is the key to consider conservative measures to avoid problems. Coronectomy is a relatively simple technique that should be taken into account when considering bulky, deeply located third molars with a high risk of paresthesia or mandibular fracture, even in presence of taurodontism.

Nonsyndromic cleft lip and palate, gastric cancer and tooth agenesis

Background

To determine the frequency of nonsyndromic cleft lip and/or palate (NSCL/P) in first-degree relatives and to analyze the prevalence of tooth agenesis in patients with gastric cancer.

Material and Methods

This cross-sectional, observational, case-control study included 798 patients attended at hospital Santa Casa in Montes Claros, Minas Gerais and Alfa Institute of Gastroenterology of the Federal University of the Minas Gerais. Information on basic demographic data and tooth agenesis of both groups and their family history of NSCL/P in first-degree relatives were evaluated. The collected information was stored in a database and analyzed using statistical program SPSS® version 21.0 and the values with p<0.05 were considered statistically significant.

Results

Of the 798 patients, 113 (14.16%) consisted of the case group and 685 of the control group (85.84%). Non-Caucasian males were the most affected, although no differences among the groups were detected. Of all participants (n=798), 66 (8.27%) presented tooth agenesis and 25 (3.13%) presented oral cleft in first degree relative.

Conclusions

Our results no found increase in the frequency of tooth agenesis in patients with gastric cancer and in the frequency of NSCL/P in the first-degree relatives of patients with gastric cancer.

Key words:Nonsyndromic cleft lip and/or palate, tooth agenesis, gastric cancer.

Cleft palate with/without cleft lip in French children: radiographic evaluation of prevalence, location and coexistence of dental anomalies inside and outside cleft region

INTRODUCTION

Prevalence of dental anomalies in cleft patients is higher than that in general population. The objectives of this study were to assess the prevalence of dental anomalies and their coexistence in French children with cleft and, then, to investigate the relation between the dental anomalies and the cleft type.

MATERIAL AND METHODS

Seventy-four non-syndromic cleft patients (6-16 years old) from Lille Regional University and Mondor-Chenevier Hospitals (France) were included. Clefts were classified as right/left unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP) and cleft palate (CP). Dental anomalies were investigated on panoramic radiographs and categorized as agenesis, supernumerary teeth, incisor rotations, impacted canines and shape anomalies. Prevalence and gender distribution of dental anomalies, mean number of affected teeth per patient, agenesis occurrence and location, and coexistence of dental anomalies were analysed by cleft type.

RESULTS

96.0% of patients presented at least one dental anomaly (agenesis 83.8%, incisor rotations 25.7%, shape anomalies 21.6%, impacted canines 18.9%, supernumerary teeth 8.1%). BCLP patients had a higher number of affected teeth, and left UCLP patients had a higher one compared to right UCLP patients. Distribution of inside (45.3%) and outside (54.7%) cleft region agenesis was similar. Adjacent (31.8%) and not adjacent (33.3%) combined dental anomalies were often encountered.

CONCLUSIONS

Dental anomalies were localized inside as well as outside cleft region and were often associated with each other. BCLP patients were more affected.

CLINICAL RELEVANCE

Early radiographic evaluation allows a comprehensive diagnosis of inside and outside cleft region anomalies, required for the multidisciplinary dental treatment.