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Rocha Cortez Teles de Alencar V, Ribeiro Paulino M, Andrea Luna Martinis de Alencar I, Ribeiro-Filho J, Valéria de Oliveira Braz A, Fagner Ferreira Matias E, Paulo Martins de Lima J, Giesta Lemos Florencio S, Douglas Melo Coutinho H, Marcos Montagner A. Assessing dental surgeons' understanding of bisphosphonates: Implications for patient health in oral surgery. Saudi Dent J 2024; 36:180-186. [PMID: 38375400 PMCID: PMC10874787 DOI: 10.1016/j.sdentj.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/16/2023] [Accepted: 09/28/2023] [Indexed: 02/21/2024] Open
Abstract
Objectives This study aimed to analyze the knowledge of dental surgeons concerning the pharmacological effects of bisphosphonates (BP) and their impact on the health of patients undergoing oral surgery treatment. Materials and methods A quantitative study was conducted with professionals in the Cariri region of Ceará, Brazil. The data were collected using a semi-structured questionnaire to interview the dental surgeons who met the inclusion criteria. The data were analyzed by Chi-square and Fischer's Exact tests using the SPSS program version 22.0. Results The results indicated that most interviewed subjects have no experience with the dental treatment of individuals under treatment with bisphosphonates. When a sample of the medication was presented, a significant number of the participants (65.3%) did not recognize the drug. Among those who recognized it, 66.5% did not know how to treat bisphosphonate-using patients in the clinical routine. However, 95.1% of the professionals who recognized the need to discontinue these drugs admitted contacting the prescriber to establish the best dental conduct. Our results also showed that recently graduated professionals better understood the need to stop BP use before invasive treatment, although they did not know the protocol. Conclusion In conclusion, a better knowledge of the pharmacological effects of BP is crucial for conducting adequate anamnesis, requesting additional tests, and performing medical monitoring, which has a significant impact on the clinical practice of dental surgeons.
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Di Fede O, Del Gaizo C, Panzarella V, La Mantia G, Tozzo P, Di Grigoli A, Lo Casto A, Mauceri R, Campisi G. Ozone Infiltration for Osteonecrosis of the Jaw Therapy: A Case Series. J Clin Med 2022; 11:jcm11185307. [PMID: 36142954 PMCID: PMC9502994 DOI: 10.3390/jcm11185307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction, mainly due to bone-modifying agents (BMA), and it is a potentially painful and debilitating condition. To date, the literature has reported a 90% rate of successful outcomes for MRONJ patients undergoing surgical treatment. Particularly for patients with advanced disease stages who are unsuitable for surgery, prolonged medical treatment is required, with a consequent risk of the overuse of antibiotics and antibiotic resistance. The aim of this study is to evaluate the efficiency and safety of ozone, via oral mucosal infiltrations, in seven cancer patients with MRONJ, who are not eligible for surgery. The protocol (OZOPROMAF) consists of intratissue injections of an oxygen ozone (O2O3) mixture, which is applied until formation of a sequestrum and clinical healing. Follow-up was scheduled to confirm the healing of MRONJ and radiological evaluations by CBCT were planned. In order to assess the level of pain, a questionnaire including the Numeric Rating Scale for Pain (NRS Pain) was administered on the first visit, one day after treatment, and one week after treatment. After an application of OZOPROMAF, all patients reported discomfort for some hours, probably due to soft tissue pressure around the infiltration site. Thereafter, the discomfort subsided within 6–8 h. Complete mucosal healing of MRONJ occurred within a number of cycles ranging from 7 to 16. Complete resolution with an improvement in bone condition was observed in all patients. The MRONJ lesions of all patients healed after 18–24 months. The authors of this study contend that these preliminary results suggest the efficiency and safety of the O2O3 mixture. However, further research is required to confirm the efficacy of the O2O3 mixtures in MRONJ treatment, at least for patients who are unsuitable for surgery.
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Affiliation(s)
- Olga Di Fede
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Carmine Del Gaizo
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Vera Panzarella
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Gaetano La Mantia
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Pietro Tozzo
- Unit of Stomatology, Azienda Ospedaliera Ospedali Riuniti “Villa Sofia-Cervello” of Palermo, Piazza Salerno, 1, 90146 Palermo, Italy
| | | | - Antonio Lo Casto
- Biomedicine, Neuroscience and Advanced Diagnostic Department, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Rodolfo Mauceri
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
- Correspondence:
| | - Giuseppina Campisi
- Unit of Oral Medicine and Dentistry for Fragile Patients, Department of Rehabilitation, Fragility and Continuity of Care, University Hospital Palermo, Via del Vespro 129, 90127 Palermo, Italy
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Lee SH, Choi SY, Bae MS, Kwon TG. Characteristics of patients with osteonecrosis of the jaw with oral versus intravenous bisphosphonate treatment. Maxillofac Plast Reconstr Surg 2021; 43:24. [PMID: 34236538 PMCID: PMC8266939 DOI: 10.1186/s40902-021-00310-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/30/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE This retrospective study was aimed to evaluate the clinical characteristics and treatment outcomes in patients with osteonecrosis of the jaw who were receiving oral versus intravenous (IV) bisphosphonate (BP). MATERIALS AND METHODS This retrospective study enrolled subjects who had been diagnosed with medication-related osteonecrosis of the jaw (MRONJ) during the period from July 2010 to June 2014. Information regarding the following demographic and clinical characteristics was collected: demographic data, administration route and type of BP, duration of BP medication, primary disease, number of involved sites, location of the lesion, number of surgeries, outcome of treatments, and laboratory test. All the patients were divided into oral and IV BP groups; and the between-group differences were compared. RESULTS Total 278 patients were divided into two groups as per the route of BP administration. The proportion of oral BP-related MRONJ group were more dominant over IV BP group (oral BP, n = 251; IV BP, n = 27). In the IV BP group, the average dosing duration (31.4 months) was significantly shorter than that in the oral BP group (53.1 months) (P < 0.001). The average number of involved sites in the oral BP group (1.21 ± 0.48) was smaller than that in the IV BP group (1.63 ± 0.84) (P < 0.001). The average number of surgeries was higher in the IV BP group (1.65 ± 0.95) as compared to that in the oral BP group (0.98 ± 0.73) (P < 0.001). Outcome after the surgery for MRONJ after IV BP was poor than oral BP group. CONCLUSION IV administration of BP causes greater inhibition of bone remodeling and could lead more severe inflammation. Therefore, even if the duration of IV administration of BP is shorter than that of oral BP, the extent of the lesion could be more extensive. Therefore, the result suggests that the MRONJ after IV BP for cancer patients needs to be considered as different characteristics to oral BP group for osteoporosis patents.
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Affiliation(s)
- Seung-Hun Lee
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Institute for Translational Research in Dentistry, Kyungpook National University, 2177 Dalgubeol-daero, Jung-gu, Daegu, 41940, Republic of Korea
| | - So-Young Choi
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Institute for Translational Research in Dentistry, Kyungpook National University, 2177 Dalgubeol-daero, Jung-gu, Daegu, 41940, Republic of Korea
| | - Min-Su Bae
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Institute for Translational Research in Dentistry, Kyungpook National University, 2177 Dalgubeol-daero, Jung-gu, Daegu, 41940, Republic of Korea
| | - Tae-Geon Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Institute for Translational Research in Dentistry, Kyungpook National University, 2177 Dalgubeol-daero, Jung-gu, Daegu, 41940, Republic of Korea.
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Romero-Ruiz MM, Romero-Serrano M, Serrano-González A, Serrera-Figallo MÁ, Gutiérrez-Pérez JL, Torres-Lagares D. Proposal for a preventive protocol for medication-related osteonecrosis of the jaw. Med Oral Patol Oral Cir Bucal 2021; 26:e314-e326. [PMID: 33037798 PMCID: PMC8141321 DOI: 10.4317/medoral.24197] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/03/2020] [Indexed: 11/18/2022] Open
Abstract
Background Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction experienced by some patients exposed to certain drugs (antiresorptives such as bisphosphonates or denosumab, and antiangiogenic drugs). From a review of the literature it appears that there is no uniform criterion when selecting preventive measures; these vary according to author. Likewise, the measures recommended are usually general, so that in few cases they result in specific actions to be applied depending on the different variables involved such as the type of drug used, the duration of its application, the underlying pathology, the presence or absence of risk factors, etc. The aim of this study has been to design a preventive protocol which can be easily applied in any clinic or by any dental care service.
Material and Methods We undertook an exhaustive literature review to find any articles related to the topic of study, namely, preventive measures for medication-related osteonecrosis of the jaw, on the one hand generically and on the other focusing on dental implant treatment. The most part the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. From 3946 items, we selected a total of 21 items.
Results From the analysis of the selected articles, several protocols have been developed that are easy to apply in a dental clinic.: Protocol 1. Before starting treatment with antiresorptives (Patients who are going to be treated for osteoporosis / Patients who are going to be treated for cancer). Protocol 2. Once treatment is initiated with antiresorptives (Patients being treated for osteoporosis / Patients being treated for cancer).
Conclusions The application of these protocols requires an interdisciplinary team which can handle the various treatments and apply the measures contained in them. Along with a team of well-educated and trained dentists, it is equally important to maintain contact with the medical team involved in the treatment of the underlying pathology, especially rheumatologists, oncologists, internists and gynaecologists. All the above requires a great staff learning and organization effort, continuous training and coordination of the whole team involved in the preventive management of these patients. Key words:Medication-related osteonecrosis of the jaw, clinical protocols, clinical guidelines, prevention.
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Affiliation(s)
- M-M Romero-Ruiz
- Dental School.University of Seville C/ Avicena s/n 41009 Sevilla, Spain
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Combined Administration of Bisphosphonates, Chemotherapeutic Agents, and/or Targeted Drugs Increases the Risk for Stage 3 Medication-Related Osteonecrosis of the Jaw: A 4-Year Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5847429. [PMID: 33123580 PMCID: PMC7584964 DOI: 10.1155/2020/5847429] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/30/2020] [Accepted: 08/11/2020] [Indexed: 11/17/2022]
Abstract
Objectives Patients with stage 3 medication-related osteonecrosis of the jaw (MRONJ) suffer from severe complications. Chemotherapeutic agents and targeted drugs are considered to be associated with the development of MRONJ. However, little is known regarding the association of those agents with stage 3 MRONJ. The purpose of this study is to analyze the comprehensive medication history of patients with advanced-stage MRONJ (stage 2 and stage 3) and evaluate the possible risk factors for stage 3 MRONJ. Patients and Methods. Sixty patients with advanced-stage MRONJ were involved in this retrospective study. Patients with developmental maxillofacial anomalies, previous radiation in the head and neck areas, and jaw bone tumors were excluded from the study. All patients were divided into two groups by their MRONJ stage (stage 2 or stage 3). Demographic and clinical characteristics, comprehensive medication data (bisphosphonates, chemotherapeutic agents, targeted drugs, and immunosuppressive agents), and results of serological biomarkers were recorded and compared between two groups. Univariate and multivariate logistic regressions were performed by SPSS 25.0 for evaluating risk factors of stage 3 MRONJ. Results Our results indicate that chemotherapy (adjusted OR = 3.43; 95% CI: 1.03 to 11.38), targeted drugs (adjusted OR = 3.69; 95% CI: 1.06 to 12.80), and maxillary lesions (adjusted OR = 4.26; 95% CI: 1.19 to 15.23) increase the risk of stage 3 MRONJ. Conclusion The outcome of this study justifies that chemotherapeutic agents and targeted drugs are probably risk factors for stage 3 MRONJ. In addition, the osteonecrosis in maxilla is more easily to develop into stage 3 MRONJ. Intense clinical observation is recommended in MRONJ patients with maxillary osteonecrosis and in those who concurrently administered bisphosphonates, chemotherapeutic agents, and/or targeted drugs. This trial is registered with ChiCTR2000032428.
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Albanese M, Zotti F, Capocasale G, Bonetti S, Lonardi F, Nocini PF. Conservative non-surgical management in medication related osteonecrosis of the jaw: A retrospective study. Clin Exp Dent Res 2020; 6:512-518. [PMID: 32614524 PMCID: PMC7545224 DOI: 10.1002/cre2.303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 12/20/2022] Open
Abstract
Objectives To date, the best treatment for Medication Related Osteonecrosis of the jaw (MRONJ) is controversial. Recent studies suggest different therapies, considering the stage of MRONJ; however, sometimes patients, although with remarkable extension of disease, cannot undergo surgery. The purpose of present preliminary study was to evaluate the efficacy of conservative non‐surgical treatment of MRONJ lesions in a cohort of patients ineligible for surgery or refusing any surgical treatment for stage II and III of MRONJ. Materials and methods Patients with MRONJ (staging II or III) ineligible for surgical treatment were selected for a retrospective study. A conservative non‐surgical therapy (antibiotics and antiseptic) was administered for 1 year. Five scheduled checks were performed to assess changes in signs and symptoms during the observational period. Results Our observation was carried out on 12 patients. Improvement of signs and symptoms of disease were observed in population. Conclusion This study suggests that non‐surgical treatment may be a valid therapeutic option in patients ineligible for surgery. The sample size is small, further studies should be carried out to satisfy the aim of a conservative non‐surgical treatment protocol establishment.
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Affiliation(s)
- Massimo Albanese
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | - Francesca Zotti
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | - Giorgia Capocasale
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | | | - Fabio Lonardi
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | - Pier Francesco Nocini
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
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Xu H, Zhou S, Qu R, Yang Y, Gong X, Hong Y, Jin A, Huang X, Dai Q, Jiang L. Icariin prevents oestrogen deficiency-induced alveolar bone loss through promoting osteogenesis via STAT3. Cell Prolif 2020; 53:e12743. [PMID: 31943455 PMCID: PMC7048209 DOI: 10.1111/cpr.12743] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/21/2022] Open
Abstract
Objectives Alveolar bone osteoporosis has attracted more and more attention because of its profound impact on stomatognathic function and treatment, but current treatments have not been targeted to alveolar bone and might even cause severe side effects. Thus, identifying the effects of anti‐osteoporosis agents on alveolar bone is essential. Icariin ameliorates metabolic dysfunction of long bones, but its effects on alveolar bone remain unclarified. Materials and methods BMSCs were isolated from rat mandibles (mBMSCs). The osteogenic potential of mBMSCs and the signalling pathway involved under icariin treatment were measured by ALP and alizarin red staining, reverse transcription‐polymerase chain reaction (RT‐PCR), Western blotting and immunofluorescence. Dual‐luciferase assay, chromatin immunoprecipitation (ChIP) and co‐immunoprecipitation were used to investigate the molecular mechanism. Ovariectomized and sham‐operated rats treated with or without icariin were analysed by micro‐CT, TRAP staining and calcein double labelling. Results We found that icariin promoted osteoblast differentiation of mBMSCs. Furthermore, STAT3 was critical for icariin‐promoted osteoblast differentiation, as indicated by increased phosphorylation levels in icariin‐treated mBMSCs, while preventing STAT3 activation blocked icariin‐induced osteoblast differentiation. Mechanistically, icariin‐promoted transcription of the downstream osteogenic gene osteocalcin (Ocn) through STAT3 and STAT3 bound to the promoter of Ocn. Notably, icariin prevented the alveolar bone osteoporosis induced by oestrogen deficiency through promoting bone formation. Conclusions For the first time, our work provides evidence supporting the potential application of icariin in promoting osteogenesis and treating alveolar bone osteoporosis.
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Affiliation(s)
- Hongyuan Xu
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Siru Zhou
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Ranyi Qu
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Yiling Yang
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Xinyi Gong
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Yueyang Hong
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Anting Jin
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Xiangru Huang
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Qinggang Dai
- The 2nd Dental Center, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
| | - Lingyong Jiang
- Center of Craniofacial Orthodontics, Department of Oral and Cranio-maxillofacial Science, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, National Clinical Research Center of Stomatology, Shanghai, China
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Santos M, Silveira K, Souza N, Costa D, Inaoka S. Extensive osteonecrosis of the maxilla caused by bisphosphonates: Report of a rare case. J Clin Exp Dent 2019; 11:e203-e207. [PMID: 30805126 PMCID: PMC6383896 DOI: 10.4317/jced.55151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022] Open
Abstract
Bisphosphonates are drugs indicated for the treatment of bone metabolic diseases or malignant hypercalcemia. They are generally well-tolerated drugs, however, recent reports have described osteonecrosis of the jaw bones as a potentially serious complication related to the long-term use of these drugs. We report a case of severe osteonecrosis in a 52-years-old white woman that was taking bisphosphonates (zoledronic acid and alendronate) for the management of osteoporosis. Following a long exposure to these drugs and after being subjected to multiples exodontias, developed bisphosphonate-related osteonecrosis of the jaw compromising the whole maxilla and that extended toward the base of skull. Due to the extent of osteonecrosis, total maxillectomy and removal of all adjacent necrotic bone were planned guided by ultraviolet light. fluorescence. This case illustrates that if not treated correctly, bisphosphonate-related osteonecrosis of the jaw may cause significant morbidity, affect the quality of life and can eventually produce significant morbidity with the dissemination to noble structures and potentially causing life-threatening complications.
Key words:Osteonecrosis, bisphosphonate, bisphosphonate-associated osteonecrosis of the jaw, maxilla, osteoporosis.
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Affiliation(s)
- Murilo Santos
- Resident Oral and Maxillofacial Surgery, Universitary Hospital Lauro Wanderley, Federal University of Paraiba
| | - Karoline Silveira
- Resident Oral and Maxillofacial Surgery, Universitary Hospital Lauro Wanderley, Federal University of Paraiba
| | - Natália Souza
- Resident Oral and Maxillofacial Surgery, Universitary Hospital Lauro Wanderley, Federal University of Paraiba
| | - Davi Costa
- Oral and Maxillofacial Surgeon of the department of Oral and Maxillofacial Surgery, Universitary Hospital Lauro Wanderley, Federal University of Paraiba
| | - Sirius Inaoka
- Oral and Maxillofacial Surgeon of the department of Oral and Maxillofacial Surgery, Universitary Hospital Lauro Wanderley, Federal University of Paraiba
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