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Djoric J, Djinic Krasavcevic A, Barac M, Kuzmanovic Pficer J, Brkovic B, Nikolic-Jakoba N. Patient discomfort and intensity of intraseptal anesthesia of computer-controlled articaine/epinephrine delivery for scaling and root planing. Clin Oral Investig 2023; 27:6221-6234. [PMID: 37644233 DOI: 10.1007/s00784-023-05238-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVES The primary aim was to assess the pain during intraseptal anesthesia (ISA) administration, as well as during and after scaling and root planing (SRP). The secondary aims pertained to comparing the pain in different jaw regions and evaluating the factors affecting pain during ISA administration, during and after SRP. MATERIAL AND METHODS ISA was obtained with three different doses of 4% articaine with 1:100,000 epinephrine (4%Ar + Ep) in 360 patients. The pain levels were measured using the visual analogue scales (VAS) for pain intensity during ISA administration (VASa), during SRP (VASi), and after SRP (VASp). These findings were then correlated with periodontal parameters. Regression analysis was performed for pain during ISA, during and after SRP. RESULTS Anesthesia administration was painful in 80.8% of cases. VASa negatively correlated with pocket depth (PPD). VASi showed no dose-dependency, except in mandibular premolars. VASi negatively correlated with the clinical attachment level (CAL). VASp positively correlated with PPD and CAL. Positive bleeding on probing reduced the chance of pain during ISA administration. Longer anesthesia duration and wider anesthetic field (orally) increased the prospects of painless SRP. CONCLUSIONS No dose-dependent differences were found regarding patient discomfort and pain intensity of ISA delivery of 4%Ar + Ep for SRP. CLINICAL RELEVANCE The pain during ISA administration was mild and well tolerated regardless of the anesthetic dose. A lower intensity of pain during SRP can be expected in patients with greater CAL. Post-treatment pain can be anticipated after SRP in the regions with greater PPD and CAL. CLINICAL TRIALS REGISTRATION NUMBER NCT04392804 (May 9th, 2020).
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Affiliation(s)
- Jelica Djoric
- Department of Periodontology and Oral Medicine, School of Dental Medicine, University of Belgrade, Dr Subotica 4, Belgrade, Serbia.
| | - Ana Djinic Krasavcevic
- Department of Periodontology and Oral Medicine, School of Dental Medicine, University of Belgrade, Dr Subotica 4, Belgrade, Serbia
| | - Milena Barac
- Department of Periodontology and Oral Medicine, School of Dental Medicine, University of Belgrade, Dr Subotica 4, Belgrade, Serbia
| | - Jovana Kuzmanovic Pficer
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, Dr Subotica 1, Belgrade, Serbia
| | - Bozidar Brkovic
- Department of Oral Surgery, School of Dental Medicine, University of Belgrade, Dr Subotica 4, Belgrade, Serbia
| | - Natasa Nikolic-Jakoba
- Department of Periodontology and Oral Medicine, School of Dental Medicine, University of Belgrade, Dr Subotica 4, Belgrade, Serbia
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Santos EC, Huller D, Brigola S, Ferreira MD, Pochapski MT, dos Santos FA. Pain management in periodontal therapy using local anesthetics and other drugs: an integrative review. J Dent Anesth Pain Med 2023; 23:245-256. [PMID: 37841520 PMCID: PMC10567545 DOI: 10.17245/jdapm.2023.23.5.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/17/2023] Open
Abstract
Background Surgical and non-surgical periodontal procedures often lead to postoperative pain. Clinicians use pharmacological methods such as anesthetics, anti-inflammatory drugs, and analgesics for relief. However, the multitude of options makes it challenging to select the best approach for routine dental care. Objective This review aimed to describe previous studies regarding the pharmacological management used for pain control during periodontal procedures as well as factors that may interfere with patients' perception of pain. Methods We included studies (period of 2000-2023, whose approach corresponded to the pharmacological protocols used for preoperative, trans-operative, and postoperative pain control in adult patients undergoing surgical and non-surgical periodontal therapy. Results A total of 32 studies were included in the analysis, of which 17 (53%) were related to anesthetic methods and 15 (47%) were related to therapeutic protocols (anti-inflammatory/analgesic agents). These studies predominantly involved nonsurgical periodontal procedures. Studies have reported that factors related to age, type of procedure, and anxiety can influence pain perception; however, only seven of these studies evaluated anxiety. Conclusions Numerous methods for pain control can be applied in periodontal therapy, which are accomplished through anesthetic methods and/or therapeutic protocols. Factors such as anxiety, age, and type of procedure are related to pain perception in patients. Thus, it is the responsibility of dentists to evaluate each clinical situation and define the best protocol to follow based on the literature.
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Affiliation(s)
| | - Daniela Huller
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Paraná, Brazil
| | - Sabrina Brigola
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Paraná, Brazil
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Graziani F, Tinto M, Orsolini C, Izzetti R, Tomasi C. Complications and treatment errors in nonsurgical periodontal therapy. Periodontol 2000 2023; 92:21-61. [PMID: 36591941 DOI: 10.1111/prd.12478] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/14/2022] [Accepted: 10/14/2022] [Indexed: 01/03/2023]
Abstract
Nonsurgical periodontal therapy can be subject to iatrogenesis, which includes all the complications directly or indirectly related to a treatment. These complications include both operator-dependent harms and errors and the consequences and adverse effects of the therapeutic procedures. The complications arising following nonsurgical periodontal treatment can be categorized as intraoperative and postoperative and can affect both soft and hard tissues at an intra-oral and extraoral level. Soft-tissues damage or damage to teeth and restorations can occur while performing the procedure. In the majority of cases, the risk of bleeding associated with nonsurgical therapy is reported to be low and easily controlled by means of local hemostatic measures, even in medicated subjects. Cervicofacial subcutaneous emphysema is not a frequent extraoral intraoperative complication, occurring during the use of air polishing. Moreover, side effects such as pain, fever, and dentine hypersensitivity are frequently reported as a consequence of nonsurgical periodontal therapy and can have a major impact on a patient's perception of the treatment provided. The level of intraoperative pain could be influenced by the types of instruments employed, the characteristics of tips, and the individual level of tolerance of the patient. Unexpected damage to teeth or restorations can also occur as a consequence of procedural errors.
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Affiliation(s)
- Filippo Graziani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Sub-Unit of Periodontology, Halitosis and Periodontal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Manuel Tinto
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Sub-Unit of Periodontology, Halitosis and Periodontal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Chiara Orsolini
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Sub-Unit of Periodontology, Halitosis and Periodontal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Rossana Izzetti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Sub-Unit of Periodontology, Halitosis and Periodontal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Cristiano Tomasi
- Department of Periodontology, Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Chugh A, Singh S, Khatana S, Gaur S, Patnana AK, Chugh V, Kumar P. The Clinical Efficacy of EMLA as a Topical Anesthetic Agent Instead of Palatal Injection During Maxillary Dental Extractions: A Randomized Controlled Trial. J Maxillofac Oral Surg 2023; 22:172-177. [PMID: 36703663 PMCID: PMC9871143 DOI: 10.1007/s12663-021-01633-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/05/2021] [Indexed: 01/29/2023] Open
Abstract
Background Even after the invention of the modern injection techniques, palatal injection still remains a painful experience for patients, and this pain is attributed to the presence of rich nerve complement and displacement of tightly adherent palatal mucosa during anesthesia. Aim To check the clinical efficacy of EMLA as a topical anesthetic agent instead of palatal injection during maxillary dental extractions. Methodology The trial includes a total of 102 participants, in whom maxillary molar extractions were indicated, were randomly divided into the experimental group (eutectic mixture of local anesthesia (EMLA) topical application was used along with buccal injection) and control group (palatal injection along with buccal injection). Pain perception during extraction was recorded using the visual analog scale (VAS). Results Mean VAS score for 'injection' in control group patients was 5.2 ± 2.08 in contrast to no pain in experimental group. In experimental group, mean VAS score on 'probing' was 0.92 ± 1.50. VAS score on 'extraction' in EMLA group was little higher though the difference was not statistically significant. The overall experience using Liekert's scale was higher in experimental group (4.0 ± 0.76) as compared to (3.3 ± 0.82) in control group leading to higher overall satisfaction among patients who underwent extraction in the experimental group. Conclusion EMLA application produced a satisfactory level of anesthesia in the palatal tissue when compared with the palatal injection.
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Affiliation(s)
| | - Surjit Singh
- Department of Pharmacology, AIIMS, Jodhpur, India
| | - Shruti Khatana
- Department of Dentistry, Adesh Medical College, Ambala, India
| | | | | | - Vinay Chugh
- Department of Dentistry, AIIMS, Jodhpur, India
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Moraes GS, Santos IBD, Pinto SCS, Pochapski MT, Farago PV, Pilatti GL, Santos FA. Liposomal anesthetic gel for pain control during periodontal therapy in adults: a placebo-controlled RCT. J Appl Oral Sci 2019; 28:e20190025. [PMID: 31778442 PMCID: PMC6882661 DOI: 10.1590/1678-7757-2019-0025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/24/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Periodontal therapy usually requires local anesthesia. If effective, a non-invasive, liposomal anesthetic gel could increase the levels of acceptance of patients in relation to periodontal therapy. OBJECTIVE This study investigated the efficacy of liposomal anesthetic gel for pain control during periodontal therapy. METHODOLOGY Forty volunteers with moderate to severe chronic periodontitis were recruited, of which at least three sextants required periodontal therapy. At least one of the selected teeth had one site with a probing depth of ≥4 mm. The volunteers received the following three gels: a placebo, lidocaine/prilocaine (Oraqix®), or a liposomal lidocaine/prilocaine, which were applied to different sextants. Pain frequency was registered during treatment and the volunteers received a digital counter to register any painful or uncomfortable experiences. At the end of each session, the volunteers indicated their pain intensity using rating scales (NRS-101 and VRS-4). The volunteers had their hemodynamic parameters measured by a non-invasive digital monitor. RESULTS Pain frequency/intensity did not show statistical difference between intervention groups. The tested gels did not interfere with the hemodynamic indices. Dental anxiety, suppuration and probing depth could influence pain during periodontal therapy. CONCLUSION Our results suggest limited indications for the use of non-invasive anesthesia when used for scaling and root planing. Intra-pocket anesthetic gel could be a good option for anxious patients, or those who have a fear of needles.
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Affiliation(s)
- Gustavo Simao Moraes
- Universidade Estadual de Ponta Grossa, Departamento de Odontologia, Ponta Grossa, Paraná, Brasil
| | | | | | - Marcia Thais Pochapski
- Universidade Estadual de Ponta Grossa, Departamento de Odontologia, Ponta Grossa, Paraná, Brasil
| | - Paulo Vitor Farago
- Universidade Estadual de Ponta Grossa, Departamento de Ciências Farmacêuticas, Ponta Grossa, Paraná, Brasil
| | - Gibson Luiz Pilatti
- Universidade Estadual de Ponta Grossa, Departamento de Odontologia, Ponta Grossa, Paraná, Brasil
| | - Fabio Andre Santos
- Universidade Estadual de Ponta Grossa, Departamento de Odontologia, Ponta Grossa, Paraná, Brasil
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Petersilka GJ, Arweiler NB, Otto J, Wittig T. Non-interventional study to collect data for the application of lidocaine gel 2% during scaling and root planing and professional mechanical plaque removal. Clin Oral Investig 2019; 23:551-558. [PMID: 29717361 PMCID: PMC7735999 DOI: 10.1007/s00784-018-2468-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 04/23/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Evaluation of the safety and efficacy of a topical lidocaine gel 2% (LG) during scaling and root planing (SRP) and professional mechanical plaque removal (PMPR). MATERIALS AND METHODS The anesthetic effects as well as unwanted effects of LG prior to or during SRP and PMPR were evaluated in an observational, non-randomized, non-interventional study design. A total of 385 treatments were recorded in 68 study centers all over Germany. Rating of the anesthetic effect of LG by treating personnel and patients using a four-item verbal rating scale (VRS), tolerability, safety (adverse effects), and need for additional local injection anesthesia (ALI). RESULTS In SRP as well as in PMPR, application of LG allowed a sufficiently pain-free therapy in more than 90% of the patients as stated on the VRS (SRP: 97.8%, PMPR: 93.75%). Overall, ALI was needed in only 4.23% of the patients treated (SRP: 5.3%, PMPR: 2.62%). One adverse effect occurred within the observation. CONCLUSIONS Application of LG may offer a safe and effective way to achieve pain-free therapy in periodontal patients. CLINICAL RELEVANCE Patient compliance is key to the success of periodontal maintenance therapy. Effective and safe pain control during various kinds of periodontal therapy might increase patient compliance and therefore contribute to the long-term treatment success, among other factors. With regard to the patients observed in this study, 47% had previously received periodontal maintenance therapy and were therefore familiar with the treatment and the associated pain.
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Affiliation(s)
- Gregor J Petersilka
- Private Practice, Wuerzburg, Germany
- Department of Periodontology, Philipps-University of Marburg, Marburg, Germany
| | - Nicole B Arweiler
- Department of Periodontology, Philipps-University of Marburg, Marburg, Germany
| | - Joachim Otto
- Medical-Scientific Department, Chemische Fabrik Kreussler & Co. GmbH, Rheingaustrasse 87-93, 65203, Wiesbaden, Germany
| | - Tobias Wittig
- Medical-Scientific Department, Chemische Fabrik Kreussler & Co. GmbH, Rheingaustrasse 87-93, 65203, Wiesbaden, Germany.
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Gupta R, Kaur S, Dahiya P, Kumar M. Comparative evaluation of efficacy of EMLA and needleless jet anesthesia in non-surgical periodontal therapy. J Oral Biol Craniofac Res 2018; 8:118-121. [PMID: 29892533 PMCID: PMC5993459 DOI: 10.1016/j.jobcr.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/07/2018] [Accepted: 04/12/2018] [Indexed: 12/27/2022] Open
Abstract
The treatment of periodontitis primarily consists of mechanical debridement carried out by means of thorough scaling and root planing that might sometimes be a painful procedure which requires the administration of some form of local anesthesia. The present study comparatively evaluates the anesthetic effect of three such forms, viz; eutectic mixture of 25 mg/g lignocaine plus 25 mg/g prilocaine (EMLA) and needleless jet anesthesia during SRP. 30 patients with probing depth of 5 mm or more and visual analog scale (VAS) score of ≥30 mm on probing were selected and asked to assess the pain by VAS and verbal rating scale (VRS) during SRP after application of the two agents. The difference between the visual analogue values of control, EMLA and Madajet XL is highly significant (p < 0.001). According to the VRS scores, 6.7% of the subjects in the EMLA group reported no pain, 80% mild pain, and 13.3% moderate pain. In the Madajet XL group, 46.7% reported no pain and 53.3% mild pain. In the control group 100% of the patients reported moderate pain when none of the anesthetic was administered. None reported severe pain. Thus, the data suggest that both anesthetics are able to produce anesthesia of the tissues. The needleless anesthesia was relatively superior in performance to EMLA.
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Affiliation(s)
| | | | - Parveen Dahiya
- Department of Periodontics, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India
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Wambier LM, de Geus JL, Boing TF, Chibinski ACR, Wambier DS, Rego RO, Loguercio AD, Reis A. Intrapocket topical anesthetic versus injected anesthetic for pain control during scaling and root planing in adult patients. J Am Dent Assoc 2017; 148:814-824.e2. [DOI: 10.1016/j.adaj.2017.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/17/2017] [Accepted: 06/17/2017] [Indexed: 11/27/2022]
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9
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Lee HS. Recent advances in topical anesthesia. J Dent Anesth Pain Med 2016; 16:237-244. [PMID: 28879311 PMCID: PMC5564188 DOI: 10.17245/jdapm.2016.16.4.237] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 11/20/2022] Open
Abstract
Topical anesthetics act on the peripheral nerves and reduce the sensation of pain at the site of application. In dentistry, they are used to control local pain caused by needling, placement of orthodontic bands, the vomiting reflex, oral mucositis, and rubber-dam clamp placement. Traditional topical anesthetics contain lidocaine or benzocaine as active ingredients and are used in the form of solutions, creams, gels, and sprays. Eutectic mixtures of local anesthesia cream, a mixture of various topical anesthetics, has been reported to be more potent than other anesthetics. Recently, new products with modified ingredients and application methods have been introduced into the market. These products may be used for mild pain during periodontal treatment, such as scaling. Dentists should be aware that topical anesthetics, although rare, might induce allergic reactions or side effects as a result of an overdose. Topical anesthetics are useful aids during dental treatment, as they reduce dental phobia, especially in children, by mitigating discomfort and pain.
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Affiliation(s)
- Hyo-Seol Lee
- Department of Pediatric Dentistry, School of Dentistry, Kyung Hee University, Seoul, Korea
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Daneshkazemi A, Abrisham SM, Daneshkazemi P, Davoudi A. The efficacy of eutectic mixture of local anesthetics as a topical anesthetic agent used for dental procedures: A brief review. Anesth Essays Res 2016; 10:383-387. [PMID: 27746520 PMCID: PMC5062240 DOI: 10.4103/0259-1162.172342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Dental pain management is one of the most critical aspects of modern dentistry which might affect patient's quality of life. Several methods are suggested to provide a painless situation for patients. Desensitization of the oral site using topical anesthetics is one of those methods. The improvements of topical anesthetic agents are probably one of the most important advances in dental science in the past 100 years. Most of them are safe and can be applied on oral mucosa with minimal irritation and allergic reactions. At present, these agents are various with different potent and indications. Eutectic mixture of local anesthetics (EMLA) (lidocaine + prilocaine) is a commercial anesthetic agent which has got acceptance among dental clinicians. This article provides a brief review about the efficacy of EMLA as a topical anesthetic agent when used during dental procedures.
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Affiliation(s)
- Alireza Daneshkazemi
- Department of Operative Dentistry, Social Determinant of Oral Health Research Center, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Seyyed Mohammad Abrisham
- Department of Prosthodontics, Yazd Dental School, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Pedram Daneshkazemi
- School of Dentistry, Shahid Behesthi University of Medical Sciences, Tehran, Iran
| | - Amin Davoudi
- Dental Students Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
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Wambier LM, de Geus JL, Chibinski ACR, Wambier DS, Rego RO, Loguercio AD, Reis A. Intra-pocket anaesthesia and pain during probing, scaling and root planing: a systematic review and meta-analysis. J Clin Periodontol 2016; 43:754-66. [PMID: 27097588 DOI: 10.1111/jcpe.12565] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2016] [Indexed: 12/17/2022]
Abstract
AIM A systematic review/meta-analysis was performed to evaluate pain during probing, scaling and root planing using intra-pocket anaesthesia versus placebo in adult patients. METHODS A search was performed in PubMed, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature database, Brazilian Library in Dentistry, Cochrane Library and Grey literature. IADR abstracts, unpublished trials registries, dissertations and theses were also searched for randomized clinical trials comparing the clinical effectiveness of intra-pocket anaesthesia and placebo. Risk/intensity of pain was the primary outcome. The risk of bias tool from the Cochrane Collaboration was used for quality assessment. Meta-analysis was performed on studies considered at low risk of bias. RESULTS A total of 1740 articles were identified. Eleven remained in the qualitative synthesis, and nine studies were considered at "low" risk of bias for meta-analysis. Standardized Hedge's g mean difference for pain intensity using visual analogue scale and Heft-Parker pain scales was -0.576 (95% confidence interval [CI] -0.94 to -0.22; p = 0.002) and for verbal rating scale pain scale it was -1.814 (95% CI -3.38 to -0.245; p = 0.023). The odds ratio for the risk of pain was 0.025 (95% CI 0.003 to 0.25; p = 0.002) and the odds ratio for the need for rescue anaesthesia it was 0.358 (95% CI 0.174 to 0.736; p = 0.005). CONCLUSIONS The anaesthetic gel decreases the risk and intensity of pain during probing/SRP.
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Affiliation(s)
- Letícia M Wambier
- Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Juliana L de Geus
- Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Ana C R Chibinski
- Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Denise S Wambier
- Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Rodrigo O Rego
- Department of Dentistry, Federal University of Ceará, Sobral, CE, Brazil
| | - Alessandro D Loguercio
- Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | - Alessandra Reis
- Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
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