Factors associated with periodontal diseases in pregnancy: Findings of the 2015 Pelotas Birth Cohort Study.

Although periodontal disease is common during pregnancy, little is known about socioeconomic, behavioral, or biological determinants related to clinically assessed periodontal condition during this period. We assessed the prevalence of periodontal disease and associated factors in pregnant women. This population-based survey used data used from the 2015 Pelotas Birth Cohort Study, Brazil. Pregnant women expected to give birth between December 2014 and May 2016 were interviewed and clinically examined by trained dentist, with periodontal measures collected in all teeth, six sites per tooth. Outcomes were periodontitis (using the 2012 Centers for Disease Control and Prevention and the American Academy of Periodontology criteria) and gingivitis (by the 2018 European Federation of Periodontology/ American Academy of Periodontology classification). Multivariate hierarchical Poisson regression was used to assess the associations between socioeconomic, systemic, and clinical oral factors and periodontal disease. A total of 2,474 pregnant women participated in the study. Prevalence of periodontitis and gingivitis was 14.63% and 21.67%, respectively. Lower educational level and calculus were associated with higher prevalence periodontitis and gingivitis (P<0.05). Smoking was also associated with periodontitis (P=0.05), and lower frequency of toothbrushing (P=0.005) with gingivitis. Periodontal disease, especially gingivitis, was prevalent in pregnant women and their determinants were socioeconomic, environmental, and clinical oral health factors.

Factors associated with periodontal diseases in pregnancy: Findings of the 2015 Pelotas Birth Cohort Study

Abstract Although periodontal disease is common during pregnancy, little is known about socioeconomic, behavioral, or biological determinants related to clinically assessed periodontal condition during this period. We assessed the prevalence of periodontal disease and associated factors in pregnant women. This population-based survey used data used from the 2015 Pelotas Birth Cohort Study, Brazil. Pregnant women expected to give birth between December 2014 and May 2016 were interviewed and clinically examined by trained dentist, with periodontal measures collected in all teeth, six sites per tooth. Outcomes were periodontitis (using the 2012 Centers for Disease Control and Prevention and the American Academy of Periodontology criteria) and gingivitis (by the 2018 European Federation of Periodontology/ American Academy of Periodontology classification). Multivariate hierarchical Poisson regression was used to assess the associations between socioeconomic, systemic, and clinical oral factors and periodontal disease. A total of 2,474 pregnant women participated in the study. Prevalence of periodontitis and gingivitis was 14.63% and 21.67%, respectively. Lower educational level and calculus were associated with higher prevalence periodontitis and gingivitis (P<0.05). Smoking was also associated with periodontitis (P=0.05), and lower frequency of toothbrushing (P=0.005) with gingivitis. Periodontal disease, especially gingivitis, was prevalent in pregnant women and their determinants were socioeconomic, environmental, and clinical oral health factors.

Oral health-related quality of life as a predictor of alcohol and cigarette consumption in adolescents.

This study evaluated the influence of Oral Health-Related Quality of Life (OHRQoL) on the consumption of alcohol and cigarette use in adolescents. This prospective cohort began in 2012 (T1) with an initial random sample of 1134 12-year-old adolescents followed for 6 years in Santa Maria, southern Brazil. The present study comprised data from the two cohort reassessments that took place in 2014 (T2) and 2018 (T3). OHRQoL was measured with the Brazilian short version of the Child Perceptions Questionnaire (CPQ11-14) at T2. Socioeconomic, demographic, and oral health measures were also collected during this period. Alcohol and cigarette consumption (regular use) in the past 30 days was evaluated at T3 through questions in the of the National School Health Survey (PeNSE) questionnaire. A multilevel Poisson regression model was used to evaluate the influence of predictor variables on substance use. Of the 770 adolescents at T2, 575 and 576 adolescents were reassessed at T3 for alcohol and cigarette consumption, respectively. Adolescents with higher overall CPQ11-14 scores were at higher risk for regular consumption of alcohol (IRR 1.01; 95% CI 1.01-1.02) and cigarette (IRR 1.04; 95% CI 1.03-1.05). Non-white adolescents with low socioeconomic status, untreated dental caries, and who had not been to the dentist (last 6 months) were also associated with increased regular consumption of licit substances. Adolescents with worse OHRQoL presented a higher consumption of alcohol and cigarette. These findings are useful for planning public health strategies to improve adolescent OHRQoL and reduce the harmful substance use.

Factors related to apical periodontitis in a southern Brazilian population: a multilevel analysis

Abstract The aim of this cross-sectional study was to evaluate the effects of individual-level and tooth-level factors on apical periodontitis (AP) in an urban population in southern Brazil. A random sample of digital panoramic radiographs (n = 545) from a dental school database was evaluated. The diagnosis of AP was determined by using a dichotomous scale (yes/no). AP was assessed according to gender, age, presence and quality of endodontic treatment (ET), presence of an intracanal post, coronal condition, and dental group. Data were analyzed descriptively and through multilevel Poisson regression analysis, considering teeth characteristics (level 1) nested in individuals (level 2). In this sample of 545 participants, the prevalence of AP was 49.5% (n =2 70) and ET was 43.5% (n = 237). Considering 13,595 teeth, AP was identified in 596 (4.4%) and ET in 617 (4.5%). Of the teeth with ET, 153 (24.8%) presented AP. Among individual-level factors, the disease was not significantly associated with gender or age. For tooth-level factors, AP was significantly associated with ET quality: teeth with short fillings (< 3 mm) and teeth with over-fillings had 2.77 (CI: 1.95-3.94, p < 0.001) and 1.08 (CI: 0.39-2.98, p < 0.001) higher prevalence of AP, respectively. There was no association between AP and age, gender, dental group, coronal condition, or the presence of an intracanal post. AP was highly prevalent in this population, and multilevel analysis indicated a significant association with ET quality.

Oral health-related quality of life as a predictor of alcohol and cigarette consumption in adolescents

Abstract: This study evaluated the influence of Oral Health-Related Quality of Life (OHRQoL) on the consumption of alcohol and cigarette use in adolescents. This prospective cohort began in 2012 (T1) with an initial random sample of 1134 12-year-old adolescents followed for 6 years in Santa Maria, southern Brazil. The present study comprised data from the two cohort reassessments that took place in 2014 (T2) and 2018 (T3). OHRQoL was measured with the Brazilian short version of the Child Perceptions Questionnaire (CPQ11-14) at T2. Socioeconomic, demographic, and oral health measures were also collected during this period. Alcohol and cigarette consumption (regular use) in the past 30 days was evaluated at T3 through questions in the of the National School Health Survey (PeNSE) questionnaire. A multilevel Poisson regression model was used to evaluate the influence of predictor variables on substance use. Of the 770 adolescents at T2, 575 and 576 adolescents were reassessed at T3 for alcohol and cigarette consumption, respectively. Adolescents with higher overall CPQ11-14 scores were at higher risk for regular consumption of alcohol (IRR 1.01; 95% CI 1.01-1.02) and cigarette (IRR 1.04; 95% CI 1.03-1.05). Non-white adolescents with low socioeconomic status, untreated dental caries, and who had not been to the dentist (last 6 months) were also associated with increased regular consumption of licit substances. Adolescents with worse OHRQoL presented a higher consumption of alcohol and cigarette. These findings are useful for planning public health strategies to improve adolescent OHRQoL and reduce the harmful substance use.

Capital social e qualidade de vida relacionada à saúde bucal de adultos do Sistema Único de Saúde / Social capital and oral health related quality of life in adults of Unified Health System

Objetivo: avaliar a influência do capital social individual na qualidade de vida relacionada à saúde bucal (QVRSB) de adultos do Sistema Único de Saúde (SUS). Métodos: este estudo transversal incluiu adultos adscritos às Estratégias da Saúde da Família (ESFs) de Santa Maria, RS. A coleta de dados foi realizada de novembro de 2019 a março de 2020 em quatro ESFs por examinadores calibrados e treinados. O capital social individual, avaliado pela participação em atividades voluntárias e a confiança em vizinhos e amigos, foi considerado o preditor do estudo. Características sociodemográficas, comportamentais e de saúde periodontal também foram coletadas. A QVRSB, considerada o desfecho, foi mensurada pelo questionário OHIP-14. Modelos de regressão de Poisson avaliaram a associação entre variáveis independentes e QVRSB. Resultados: ao total, 80 adultos foram incluídos. Indivíduos do sexo feminino, da cor da pele não branca, com menor renda familiar mensal, fumantes, que visitaram o serviço odontológico a menos de um ano e que possuíam sangramento gengival apresentaram altos scores totais de OHIP-14 (P<0,05). A não participação em atividades voluntárias [razão de média (RR): 1,24; intervalo de confiança (IC) 95%: 1,03-1,50] e a ausência de confiança em vizinhos e amigos (RR: 1,24; IC 95%: 1,08-1,43) foram associadas a uma pior QVRSB dos adultos. Conclusão: a ausência de um capital social individual influenciou negativamente a QVRSB de adultos usuários do SUS.(AU)

Objective: To evaluate the influence of individual social assets on oral health-related quality of life (OHRQoL) of adult users of the Brazilian Unified Health System (UHS). Methods: This cross-sectional study included adults of the Family Health Strategy (FHS) of Santa Maria, RS. Data collection was performed from November 2019 to March 2020 in four FHSs by calibrated and trained examiners. Individual social capital, assessed by participation in volunteer activities and trust in neighbors and friends, was considered the predictor of the study. Sociodemographic, behavioral, and periodontal health characteristics were also collected. The OHRQoL, considered the outcome, was measured using the OHIP-14 questionnaire. Poisson regression models assessed the association between independent variables and OHRQoL. Results: In total, 80 adults were included. Female subjects, of non-white skin color, with lower monthly family income, smokers, who visited the dental service less than one year ago and who had gingival bleeding had high total OHIP-14 scores (P<0.05). Non-participation in voluntary activities [rate ratio (RR): 1.24; confidence interval (CI) 95%: 1.03-1.50] and the lack of trust in neighbors and friends (RR: 1.24; 95% CI: 1.08-1.43) were associated with a worse OHRQoL of adults. Conclusion: The absence of individual social assets negatively influenced the OHRQoL of adult UHS users.(AU)

Associação entre equipe de saúde bucal da Estratégia de Saúde da Família e qualidade de vida relacionada à saúde bucal em adultos / Association between the dental health team of the Family Health Strategy and oral health related quality of life in adults

Objetivo: avaliar a influência da equipe de saúde bucal (eSB) na qualidade de vida relacionada à saúde bu-cal (QVRSB) de adultos. Métodos: a amostra deste estudo transversal foi composta por adultos adscritos às Estratégias de Saúde da Família (ESFs) de Santa Maria, RS. Variáveis sociodemográficas, como idade, sexo, cor da pele, renda familiar e escolaridade, foram avaliadas através de questionário semiestruturado. Variáveis de serviço odontológico foram mensuradas através do motivo de procura ao serviço e da presença de eSB, avaliada a partir dos dados oficiais do município. Biofilme dental, sangramento gengival e cárie dental foram coletados através de exame clínico odontológico. O desfecho foi a QVRSB mensurada pelo questionário OHIP-14. Modelos foram construídos por meio de regressão de Poisson, para avaliar a associação entre presença de eSB e QVRSB. Resultados: ao total, 80 adultos adscritos a quatro ESF (duas com eSB) foram in-cluídos. A ausência da eSB influenciou negativamente a QVRSB de adultos (razão de média: 1,21; intervalo de confiança de 95%: 1,07-1,36). Além disso, idade, cor da pele não branca, menor renda familiar, menor escolaridade, procura ao serviço odontológico por dor dental e pior saúde bucal foram associados a uma pior QVRSB (P<0,05). Conclusão: indivíduos sem acesso à eSB apresentaram uma pior QVRSB. Estratégias de promoção de saúde devem incluir a ampliação do acesso à ESF, aumentando a equidade no acesso aos cuidados odontológicos.(AU)

Objective: to assess the influence of dental health team (DHT) on the oral health-related quality of life (OHRQoL) of adults. Methods: the sample of this cross-sectional study consisted of adults enrolled in the Family Health Strategy (FHS) in Santa Maria, RS. Sociodemographic variables such as age, sex, skin color, family income and education level were assessed using a semi-structured questionnaire. Dental service variables were measured through the reason for attending for the service and the presence of DHT, evaluated from the official data of the municipality. Dental biofilm, gingival bleeding and dental caries were collected through clinical dental examination. The outcome was OHRQoL, measured by the OHIP- 14 questionnaire. Models were built using Poisson regression to assess the association between the presence of DHT and OHRQoL. On total, 80 adults enrolled in four FHS (two with DHT) were included. The absence of DHT negatively influenced the OHRQoL of adults [mean ratio: 1.21; 95% confidence interval: 1.07-1.36]. In addition, age, non-white skin color, lower family income, less education, attending dental care due to dental pain and poorer oral health were associated with worse OHRQoL (P<0.05). Conclusion: individuals without access to DHT had a worse OHRQOL. Health promotion strategies should include expanding access to FHS, increasing equity in access to dental care.(AU)

Impact of the brazilian family health strategy on child oral health-related quality of life: a cohort study

Abstract Most of the Brazilian population is covered by the Family Health Strategy (FHS), however no longitudinal study has assessed the impact of the FHS on child oral health-related quality of life (OHRQoL). The objective of the study was to evaluate the longitudinal impact of the FHS on the OHRQoL. This study followed up 459 children aged 2 to 5 years for 2 years. OHRQoL was assessed by the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS) at baseline (April to November 2016) and follow-up (April to December 2018). Children's parents answered a questionnaire regarding sociodemographic information, FHS service, and dental service. Participants were clinically examined for dental caries. Multilevel Poisson regression was used to assess the associations between FHS variables at baseline and overall/domain-specific of the ECOHIS scores over time. A total of 365 children were reassessed for OHRQoL (follow-up rate: 79.5%). The absence of FHS coverage from the child's first year of age was associated with higher scores in the family function domain [rate ratio (RR) = 2.42; 95% confidence interval (CI) 1.28-4.58)]. Home visits by the FHS team members were associated with higher psychological domain scores (RR = 1.60; 95%CI 1.01-2.57). Children not covered by the FHS since the first year of age reported worse OHRQoL over time. This fact highlights the importance of an integrated health approach to promote children's health.

Gingivitis influences oral health-related quality of life in adolescents: findings from a cohort study / A gengivite influencia a qualidade de vida relacionada à saúde bucal de adolescentes: achados de um estudo de coorte

ABSTRACT: Introduction: Oral health-related quality of life (OHRQoL) is affected by different clinical conditions. The aim of this study was to evaluate the impact of gingivitis on OHRQoL in adolescents. Methodology: This cohort study consisted of a random sample of 1,134 schoolchildren enrolled during 2012, in Santa Maria, Brazil. After two years, 743 adolescents were follow-up (response rate: 65.5%). Clinical, socioeconomic and OHRQoL data were collected. OHRQoL was assessed by the short Brazilian version of the Child Perceptions Questionnaire 11-14 (CPQ11-14), and gingival bleeding through Community Periodontal Index. Gingivitis was considered with the presence of 15% or more bleeding sites. Poisson regression models were used to evaluate the association between gingivitis and overall and domain-specific CPQ11-14 scores. Prevalence of gingivitis at baseline was considered the main predictor for the OHRQoL at follow-up. Results: Gingivitis at baseline was associated with higher overall CPQ 11-14 score (RR = 1.07; 95%CI 1.01 - 1.14), and emotional well-being (RR = 1.17; 95%CI 1.04 - 1.31), independently of other oral conditions and socioeconomic variables. Conclusions: The findings indicate that gingivitis negatively impacts the adolescents' OHRQoL. Moreover, gender, maternal schooling and household income were also associated with OHRQoL.

RESUMO: Introdução: Qualidade de vida relacionada à saúde bucal (QVRSB) é afetada por diferentes condições clínicas. O objetivo deste estudo foi avaliar o impacto da gengivite na QVRSB de adolescentes. Metodologia: Este estudo de coorte consistiu em uma amostra aleatória de 1.134 escolares iniciado em 2012, na cidade de Santa Maria, Brasil. Após dois anos, 743 adolescentes foram acompanhados (taxa de resposta: 65,5%). Dados clínicos, socioeconômicos e de QVRSB foram coletados. A QVRSB foi avaliada pela versão brasileira curta do Child Perceptions Questionnaire 11-14 (CPQ11-14) e o sangramento gengival foi coletado através do Índice Periodontal Comunitário. Gengivite foi considerada com o indivíduo apresentando 15% ou mais locais de sangramento. Os modelos de regressão de Poisson foram utilizados para avaliar a associação entre gengivite e os escores total e específico do domínio do CPQ11-14. A prevalência de gengivite na primeira avaliação foi considerada o preditor principal para a QVRSB no acompanhamento. Resultados: A gengivite no baseline foi associada à maior pontuação geral do CPQ 11-14 (RR = 1,07; IC95% 1,01 - 1,14) e ao domínio de bem-estar emocional (RR = 1,17; IC95% 1,04 - 1,31), independentemente das outras condições orais e variáveis socioeconômicas. Conclusão: Os achados indicam que a gengivite impacta negativamente a QVRSB de adolescentes. Além disso, sexo, escolaridade materna e renda familiar mensal também foram associados à QVRSB.

Family religiosity and oral health related quality of life: a multilevel analysis in brazilian schoolchildren

Abstract Religiosity has been associated with a better dental condition and positive self-perception of health, but there are no studies on the relationship between religious practice and oral health-related quality of life (OHRQoL), especially among schoolchildren. Thus, the aim of this study was to evaluate the association between family religiosity and OHRQoL in 12-year-old schoolchildren. We conducted a cross-sectional study in a representative sample of 12-year-old schoolchildren from Santa Maria, a city in southern Brazil. A total of 1,134 schoolchildren were assessed in a randomly selected in 20 public schools in the city. Participants were examined by 4 calibrated dentists (minimum Kappa-value for intra and inter-examiner agreement were 0.79 and 0.77, respectively) according to dental caries (Decayed, Missed, Filled Teeth Index), and gingival bleeding (Community Periodontal Index criteria). OHRQoL was assessed by the Brazilian short version of Child Perceptions for Questionnaire (CPQ11-14). Parents or guardians answered a structured questionnaire regarding their socioeconomic status and religious practice. Data were analyzed using multilevel Poisson regression analysis to assess the association of religiosity and overall and domain-specific CPQ 11-14 scores. Religious practice less than once a week was associated with higher mean symptoms domain scores and higher mean CPQ 11-14 overall scores in schoolchildren. In conclusion, our findings demonstrate that family religiosity was positively associated with schoolchildren's OHRQoL.

Resumo A religiosidade tem sido associada a uma melhor condição dentária e autopercepção positiva de saúde, mas não há estudos sobre a relação entre a prática religiosa e qualidade de vida relacionada à saúde bucal (QVRSB), especialmente entre escolares. Assim, o objetivo deste estudo foi avaliar a associação entre religiosidade da família e a QVRSB em escolares de 12 anos de idade. Nós realizamos um estudo transversal em uma amostra representativa de escolares de 12 anos de idade de Santa Maria, uma cidade no sul do Brasil. Um total de 1.134 escolares foram avaliados em uma seleção aleatória em 20 escolas públicas da cidade. Os participantes foram examinados por 4 dentistas calibrados (valor mínimo do Kappa para concordância intra e inter-examinador foi de 0,79 e 0,77, respectivamente) de acordo com cárie dental (Índice de Dentes Cariados, Perdidos e Obturados) e sangramento gengival (Índice Periodontal Comunitário). QVRSB foi avaliada pela versão reduzida brasileira do Child Perceptions for Questionnaire (CPQ11-14). Os pais ou responsáveis responderam a um questionário estruturado sobre sua condição socioeconômica e prática religiosa. Os dados foram analisados usando análise de regressão de Poisson multinível para avaliar a associação de religiosidade e escores de QVRSB geral e por domínio específico. A prática religiosa menos de uma vez por semana foi associada com maior escore do domínio sintomas orais e maior média do escore total do CPQ 11-14 em escolares. Em conclusão, nossos achados demonstram que religiosidade familiar foi positivamente associada com a QVRSB dos escolares.

Condição periodontal e câncer: uma revisão de literatura / Periodontal condition and cancer: a literature review

Introdução: Estudos sugerem a relação entre doença periodontal e condições sistêmicas, dentre elas o câncer. A plausibilidade biológica desta possível associação é o aumento de marcadores inflamatórios na corrente sanguínea devido a uma infecção crônica. Objetivo: Revisar a literatura sobre a associação entre a condição periodontal e câncer em sítios específicos, bem como analisar a influência de fatores de risco e confundimento nessa inter-relação. Materiais e Métodos: A busca da literatura foi realizada na base de dados PubMed, utilizando as palavras-chave: "periodontal diseases"; "tooth loss"; "inflammation"; "risk factors" e "cancer". A busca foi limitada a artigos a partir do ano 2000, com delineamento caso-controle e coorte incluindo seres humanos. Resultados: Alguns estudos demonstraram associações estatisticamente significantes entre avaliações das medidas periodontais e/ ou a perda dentária, principalmente para o câncer oral e do trato gastrointestinal superior, além do câncer de mama, hematológico, de pâncreas e de pulmão, em diferentes populações. Essas associações persistem em alguns estudos mesmo após o ajuste para fatores de risco como o fumo, a condição socioeconômica e o consumo de álcool. Conclusões: Esta revisão de literatura sugere que o quadro inflamatório associado às doenças periodontais tem um possível papel no processo de carcinogênese, independente de outros fatores de risco associados. Porém, nenhum estudo apresentou resultados conclusivos sobre influência do quadro inflamatório periodontal na carcinogênese.(AU)

Introduction: Studies suggest the relationship between periodontal disease and systemic conditions, among them cancer. The biological plausibility of this possible association is the increase in inflammatory markers in the bloodstream due to a chronic infection. Aim: To review the literature about the association between periodontal status and cancer at specific sites and to analyze the influence of risk factors and confounding in this interrelationship. Methodology: The literature search was conducted in PubMed database using the keywords: "periodontal diseases"; "tooth loss"; "inflammation"; "risk factors" and "cancer". The search was limited to articles from 2000, with case-control and cohort including humans. Results: Some studies have shown statistically significant association between periodontal evaluation of measures and/ or tooth loss, especially for oral and upper gastrointestinal tract cancer, and breast cancer, hematologic, pancreas and lung, in different populations. These associations persist in some studies even after adjusting for risk factors such as smoking, socioeconomic status and alcohol consumption. Conclusion: This literature review suggests that the inflammatory process associated with periodontal disease have a possible role in the carcinogenesis process, independent of other risk factors. However, no study showed conclusive results about the influence of periodontal inflammatory process in carcinogenesis. (AU)

Correlations between supra- and subgingival clinical parameters in smokers and individuals who have never smoked / Correlações entre parâmetros clínicos supra e subgengivais em fumantes e em indivíduos que nunca fumaram

Introduction: Smoking is a risk factor for prevalence, severity and progression of periodontal disease and appears to suppress marginal periodontium inflammatory response. Purpose: To correlate Visible Plaque Index (VPI) and Gingival Bleeding Index (GBI) in smokers and never-smokers, as well as GBI and bleeding on probing (BOP ) in these groups. Material and method: We used baseline data of one quasi-experimental study in which 11 smokers and 14 subjects who never smoked were submitted to clinical periodontal examinations between September 2010 and October 2011. Result: The correlation between VPI and GBI was positive for both groups, it was strong and statistically significant in subjects who had never smoked and moderate in smokers. Regarding GBI and BOP correlations were moderate for smokers and weaker for individuals who had never smoked. Conclusion: Smokers have lower strength correlation between VPI and GBI compared to individuals who had never smoked resulting in a less pronounced marginal gingival bleeding. .

Introdução: O hábito de fumar é um fator de risco importante na prevalência, progressão e gravidade das doenças periodontais e parece suprimir a resposta inflamatória marginal no periodonto. Objetivo: Correlacionar Índice de Placa visível (IPV) e Índice de Sangramento Gengival (ISG) em fumantes e indivíduos que nunca fumaram, bem como correlacionar ISG e o sangramento à sondagem (SS) nesses dois grupos. Material e método: Foram utilizados dados de baseline de um estudo quasi-experimental, no qual 11 pacientes fumantes e 14 indivíduos que nunca fumaram foram submetidos a exames clínicos periodontais no período de setembro de 2010 e outubro de 2011. Resultado: A correlação entre IPV e ISG foi positiva para ambos os grupos, sendo forte e estatisticamente significante nos indivíduos que nunca fumaram e moderada nos fumantes. Com relação ao ISG e SS houve moderada correlação para os fumantes e fraca para os indivíduos que nunca fumaram. Conclusão: Fumantes apresentam uma correlação entre IPV e ISG de menor força em relação aos indivíduos que nunca fumaram resultando em um sangramento gengival marginal menos pronunciado. .