Myiasis on the tongue of a patient hospitalized in a psychiatric ward: A case report with a focus on diagnosis and clinical management.

INTRODUCTION: Myiasis is a disease caused by the infestation of fly larvae in the skin, which complete part of their life cycle by feeding on host tissues. OBJECTIVE: To report a rare case of tongue myiasis in a patient admitted to a psychiatric ward, focusing on clinical management. CASE REPORT: A dependent care and mentally challenged 55 years old male patient was hospitalized in a psychiatric ward. After 42 days, during the intraoral examination, it was noted numerous larvae peeking from inside of a wound on the dorsum of the tongue. The clinical diagnosis of myiasis was rendered. For the treatment, manual removal was performed initially and ivermectin (15 mg), metamizole sodium (500 mg/ml), and chlorhexidine digluconate (0.12%) were prescribed. After one week, larvae were no longer observed, and the wound was completely healed. CONCLUSION: Myiasis occurrence is uncommon in the mouth, however, its correct diagnosis and treatment are necessary to avoid further damage to patients, especially those who are hospitalized.

Morphological analysis of cell cannibalism: An auxiliary tool in the prediction of central giant cell granuloma clinical behavior.

Central giant cell granuloma (CGCG) is a benign jaw lesion with variable clinical behavior. Cell cannibalism is a cellular process associated with aggressiveness and invasion in malignant neoplasms. Here, we morphologically investigated cell cannibalism as an auxiliary method to predict CGCG clinical behavior. Cell cannibalism was quantitatively evaluated in 19 cases of peripheral giant cell granuloma (PGCG), 38 cases of CGCG (non-aggressive and aggressive), and 19 cases of giant cell tumor of bone (GCT) stained with hematoxylin and eosin. T-test was performed to assess the differences between the variables analyzed (p ≤ 0.05). Cell cannibalism was identified in 21% of non-aggressive CGCGs and 68.4% of aggressive CGCGs. A significantly higher amount of cannibal multinucleated giant cells (CMGC) was observed in aggressive CGCG compared to PGCG and non-aggressive CGCG (p = 0.042; p = 0.044, respectively). There were no significant differences in the CMGC index between non-aggressive CGCG and PGCG (p = 0.858) and between aggressive CGCG and GCT (p = 0.069). CGGC cases that exhibited rapid growth and tooth displacement and/or root resorption had a higher amount of CMGC (p = 0.035; p = 0.041, respectively). Cell cannibalism can be identified in CGCG through routine anatomopathological examination. The quantification of CMGC can help to predict the clinical behavior of central giant cell granuloma.

Adverse Reactions Associated with Dermal Fillers in the Oral and Maxillofacial Region: A Venezuelan Experience.

BACKGROUND: Dermal facial fillers are increasingly popular. Published reports on the clinical and histopathologic characteristics related to adverse reactions to dermal fillers in the facial region have been relatively well documented. This study adds to the literature on adverse reactions to injected filler in the oral and maxillofacial region in a South American population. METHODS: A retrospective, descriptive cross-sectional study (2019-2020) was performed. The study population was a dermatology service in Venezuela. Clinical and histopathologic features of patients with adverse effects were documented. RESULTS: A total of 35 cases of adverse reactions associated with cosmetic filler procedures were diagnosed during the analyzed period; of these, six cases (17.1%) involved the oral and maxillofacial region. All cases occurred in women. The mean age at diagnosis was 59.3 years (58-73). In three cases, dermal fillers were used in different locations on the face, while three involved the lips. Five patients exhibited adverse reactions to lip filler. All six cases were histopathologically diagnosed as foreign body reactions to injected material. Four and two cases revealed microscopic features compatible with hyaluronic acid and polymethylmethacrylate, respectively. CONCLUSION: Reflecting the dramatic increase in cosmetic procedures with soft tissue fillers, this study contributed by reporting six cases of foreign body reaction involving the oral and maxillofacial region, confirmed with biopsy and histopathology.

Clinicopathologic analysis of oral dermoid and epidermoid cysts: a Brazilian multicenter study.

Dermoid cysts (DCs) and epidermoid cysts (ECs) are uncommon developmental cysts affecting the oral cavity. This study aims to evaluate patients with oral DCs and ECs and their demographic and clinicopathologic features. A retrospective descriptive cross-sectional study was performed. A total of 105,077 biopsy records of oral and maxillofacial lesions from seven Brazilian oral pathology centers were analyzed. All cases diagnosed as oral DCs and ECs were reviewed, and clinical, demographic, and histopathological data were collected. The series comprised 32 DCs (31.4%) and 70 ECs (68.6%). Most of the DCs occurred on the floor of the mouth (n = 14; 45.2%) of women (n = 17; 53.1%) with a mean age of 34.6 ± 21.6 years. All DCs were lined partially or entirely by stratified squamous epithelium (100%). Chronic inflammatory cells, melanin pigmentation, multinucleated giant cell reaction, and cholesterol clefts were observed in the fibrous capsule . Most of the ECs affected the labial mucosa (n = 20; 31.7%) of men (n = 39; 56.5%) with a mean age of 48.0±19.8 years. Microscopically, most ECs (n = 68; 97.1%) were lined entirely by stratified squamous epithelium. Two cysts (2.9%) showed areas of respiratory metaplasia. Chronic inflammatory cells, melanin pigmentation, multinucleated giant cell reaction, and cholesterol clefts were also observed in the fibrous capsule. Conservative surgical excision was the treatment of choice in all cases. Oral DCs and ECs are uncommon and often clinically misdiagnosed lesions. Clinicians should consider DCs and ECs in the differential diagnosis of soft tissue lesions in the oral cavity, mainly located on the floor of the mouth and labial mucosa.

Biological marker for the establishment of periodontal disease: cross-sectional study in the gingival tissue.

BACKGROUND: The present study investigated the expression of COX-2, EMMPRIN, HIF-1α, and GLUT-1 in the gingival tissue to verify if there is a correlation between the immunoexpression of these proteins and the changes caused by the inflamed infiltrate present in the gingival tissues. MATERIAL AND METHODS: A morphological analysis of epithelial changes (hyperplasia, exocytosis, spongiosis, and hydropic degeneration) was performed, as well as a semiquantitative analysis of the immunoexpression of COX-2, EMMPRIN, HIF-1α, and GLUT-1 in the epithelium and connective tissue of 60 specimens of gingival tissue. RESULTS: Epithelial immunoexpression to COX-2 was observed in three cases, while EMMPRIN, HIF-1α, and GLUT-1 were strongly expressed in the basal layer of the epithelium and gradually decreased until the upper layers. In the connective tissue, COX-2 immunoexpression showed a statistically significant association (p < 0.001) with the gingival inflammatory infiltrate. In connective tissue, EMMPRIN and HIF-1α exhibited intense immunopositivity, while GLUT-1 was negative in most cases. CONCLUSION: COX-2 expression may constitute a biological marker of gingival tissues since its epithelial immunoexpression may indicate a greater propensity for the establishment of periodontal disease.

Necrotizing sialometaplasia: A report of two cases and review of the literature.

Necrotizing sialometaplasia (NS) affects salivary glands, and despite being a benign condition, its clinical and histopathological features sometimes mimic other malignant pathologies of epithelial origin. This article presents two cases of NS and discusses clinicopathological features and the differential diagnosis of this condition. The first case, a 76-year-old woman with a 6-month history of painful oral thrush. Intraoral examination showed an ulcerative lesion located on the hard palate. The clinical hypothesis was squamous cell carcinoma. Second, a 26-year-old man with a 40-days ulcerative lesion on the soft palate. Intraoral examination revealed a reddish ulcer measuring 0.5 cm. Clinical hypothesis was traumatic ulcer. In both cases, a biopsy was performed, and a histopathological diagnosis of NS was established. NS cause is poorly understood, and its clinical features resemble other oral lesions with ulcerative aspects. Thus, dentists must be aware of the clinical features of oral ulcers with more than a 2-week duration without defined etiology.

Analysis of nine cases of oral foreign body granuloma related to biomaterials.

Foreign bodies can penetrate the interior of soft and, sometimes, hard, tissues in various ways, including through open wounds, lacerations and traumatic accidents. However over the years, evidence of links between the use of dental materials and lately, significant involvement of aesthetic filler materials as foreign bodies in the oral and perioral region have been reported. Foreign body granulomas (FBGs) may develop from this exogenous material, histopathologically characterized by the presence of chronic inflammation and a high amount of macrophages. This study presents nine FBG cases affecting the oral and perioral regions, and carries out a literature review on the main clinical, histopathological and material characteristics used in dental and dermatological procedures related to the appearance of this type of granuloma.

Clinical and histopathological features of nasopalatine duct cyst: A 47-year retrospective study and review of current concepts.

PURPOSE: To evaluate the clinical and histopathological features of nasopalatine duct cysts (NDCs) stored in the archives of a referred Oral Pathology Service over a 47-year-period, and to review current concepts about these cysts. MATERIAL AND METHODS: All NDCs were reviewed, and clinical data were obtained from the patient records. Thirty cases were re-evaluated microscopically by 2 oral pathologists. RESULTS: Among 14,564 cases, 30 (0.20%) were NDCs. Fifteen (50.0%) of the patients were female, and the mean age was 42.7 years. The lesions measured on average 2.37 ± 1.69 cm. Histologically, stratified squamous epithelium, alone or in combination with other epithelia, was present in 13 (46.6%) cases. Goblet cells and subepithelial hyalinization were common. Fourteen (46.6%) cases exhibited a slight degree of inflammation. Nerves were observed in 15 (50%) cases and mucous glands in 7 (23.3%). Hyaline ring granulomas (which is described here for the first time in NDC) and cholesterol crystals were not common. CONCLUSION: Knowledge of clinical-histopathological aspects of NDCs provides more accurate data about their nature and behavior. Our results suggest that the predominant epithelial lining of these cystic lesions is exclusively stratified squamous epithelium or combined with another type. Vessels, nerves, mucous glands and inflammatory infiltrate are frequently observed.

Solitary fibrous tumor: Two cases report with a focus on the differential diagnosis / Tumor Fibroso Solitário: Relato de dois casos com foco no diagnóstico diferencial

Solitary fibrous tumor (SFT) is a neoplasm of fibroblastic/myofibroblastic origin with intermediate biological behavior. We report here two cases of SFT affecting an unusual anatomical site in 58-year-old and 40-year-old female patients and discuss the differential diagnosis of this lesion. In case 01, the lesion showed the clinical appearance of an asymptomatic "blister" with normal color, rubbery consistency, measuring 0.3 cm, and affected the lower lip; while in case 02, a symptomatic red nodular lesion with a soft consistency and measuring 0.5 cm affected the floor of the mouth. Excisional biopsies were performed. Microscopically, two well-delimited benign neoplasms were observed, exhibiting the proliferation of ovoid to spindle-shaped mesenchymal cells, vascular spaces with staghorn arrangement, and the absence of mitosis figures. Immunohistochemistry was performed in case 01 to assist in the diagnosis. Weak and diffuse immunostaining was observed for α-SMA and intense and diffuse immunopositivity for Bcl-2 and CD34. Based on histopathological and immunohistochemical features, a diagnosis of SFT was rendered in both cases. The low occurrence and nonspecific clinical features of oral SFT may make its clinical diagnosis difficult. Also, morphological and immunohistochemical are essential for differential diagnosis with other mesenchymal neoplasms.(AU)

O tumor fibroso solitário (TFS) é uma neoplasia de origem fibroblástica/miofibroblastica com comportamento biológico intermediário. Nesse artigo relatamos dois casos de TFS afetando sítios anatômicos incomuns em pacientes do sexo feminino de 58 anos e 40 anos e discutir os seus diagnósticos. No caso 01 clinicamente a lesão apresentou um aspecto de "bolha" assintomática, coloração normal da mucosa, consistência borrachoide medindo 0,3 cm, em região de lábio inferior, enquanto que no caso 02, como uma lesão sintomática, vermelha, nodular com consistência mole e medindo 0,5 cm afetando o assoalho bucal. As biópsias excecionais foram realizadas. Microscopicamente, observamos duas lesões neoplásicas bem delimitadas exibindo uma proliferação de células mesenquimais variando de ovoides a fusiformes, vasos sanguíneos em formato de "chifre de veado", com ausência de figuras de mitoses. No caso 01 foi realizado análise imuno-histoquímica para auxiliar no diagnóstico. Foi observado uma marcação fraca e difusa de α-SMA e uma intensa e difusa imunopositividade para o Bcl-2 e CD34.Baseado nos achados histopatológicos e imuno-histoquímicos o diagnóstico de TFS foi estabelecido em ambos os casos. A baixa ocorrência e os achados clínicos inespecíficos do TFS oral podem dificultar o diagnóstico clínico. Além disso, as análises morfológicas e imuno-histoquimicas são essenciais para realização do diagnóstico diferencial com outras neoplasias mesenquimais.(AU)_

Clinicopathologic analysis of oral dermoid and epidermoid cysts: a Brazilian multicenter study

Abstract Dermoid cysts (DCs) and epidermoid cysts (ECs) are uncommon developmental cysts affecting the oral cavity. This study aims to evaluate patients with oral DCs and ECs and their demographic and clinicopathologic features. A retrospective descriptive cross-sectional study was performed. A total of 105,077 biopsy records of oral and maxillofacial lesions from seven Brazilian oral pathology centers were analyzed. All cases diagnosed as oral DCs and ECs were reviewed, and clinical, demographic, and histopathological data were collected. The series comprised 32 DCs (31.4%) and 70 ECs (68.6%). Most of the DCs occurred on the floor of the mouth (n = 14; 45.2%) of women (n = 17; 53.1%) with a mean age of 34.6 ± 21.6 years. All DCs were lined partially or entirely by stratified squamous epithelium (100%). Chronic inflammatory cells, melanin pigmentation, multinucleated giant cell reaction, and cholesterol clefts were observed in the fibrous capsule . Most of the ECs affected the labial mucosa (n = 20; 31.7%) of men (n = 39; 56.5%) with a mean age of 48.0±19.8 years. Microscopically, most ECs (n = 68; 97.1%) were lined entirely by stratified squamous epithelium. Two cysts (2.9%) showed areas of respiratory metaplasia. Chronic inflammatory cells, melanin pigmentation, multinucleated giant cell reaction, and cholesterol clefts were also observed in the fibrous capsule. Conservative surgical excision was the treatment of choice in all cases. Oral DCs and ECs are uncommon and often clinically misdiagnosed lesions. Clinicians should consider DCs and ECs in the differential diagnosis of soft tissue lesions in the oral cavity, mainly located on the floor of the mouth and labial mucosa.

COVID-19 in dental practice ­ an overview of challenges and preventive measures / COVID-19 na prática odontológica ­ uma revisão sobre os desafios e medidas preventivas

COVID-19 was identified to be caused by a new coronavirus named as SARS-CoV-2. Since the outbreak of this disease, World Health Organization (WHO) declared a global public health emergency. SARS-CoV-2 has a high estimate rate of human-tohuman transmission mainly through inhalation/ingestion/direct mucous contact with respiratory droplets. Considering this high transmission capacity, several countries have already registered cases of infection by health professionals. Even though dentists are not directly involved in the diagnosis and therapy of COVID-19 they represent undoubtedly a risk group due to high exposure and their work environment is a contagion factor for patients and staff. In this manner, the objective of this article is to approach important aspects of COVID-19 concerning dental care and provides an overview of its challenges on dental practice. For this, we used these following keywords in our research: COVID-19; dental general practice; prevention and control; infectious disease transmission; infectious disease transmission, patient to professional. Taking into account the global concern with patient care in midst of this pandemic, we address valid concerns regarding the potential means of contamination in the dental office and highlight practices and guidelines adopted in different countries to minimize risks in dental care in this global public health crisis, thus, reinforcing the challenges of dentistry in this context, highlighting the importance of rigorous preventive measures. However, there is still a lack of standardization of dental care protocols and consequently, reduce the risk of contagion.

COVID-19 foi identificada como sendo causada por um novo coronavírus denominado SARS-CoV-2. Desde o surgimento da doença, a Organização Mundial da Saúde (OMS) declarou uma emergência global de saúde pública. O SARS-CoV-2 tem uma alta taxa estimada de transmissão de pessoa para pessoa, principalmente por inalação/ingestão/contato direto da mucosa com gotículas respiratórias. Considerando essa alta capacidade de transmissão, vários países já registraram casos de infecção por profissionais de saúde. Mesmo que os dentistas não estejam diretamente envolvidos no diagnóstico e terapia do COVID-19, eles representam, sem dúvida, um grupo de risco devido à alta exposição e seu ambiente de trabalho é um fator de contágio para pacientes e equipe. Dessa forma, o objetivo deste artigo é abordar aspectos importantes do COVID-19 no que diz respeito à assistência odontológica e apresentar um panorama de seus desafios na prática odontológica. Para isso, utilizamos as seguintes palavras-chave em nossa pesquisa: COVID-19; clínica odontológica geral; prevenção e controle; transmissão de doenças infecciosas; transmissão de doenças infecciosas do paciente para o profissional. Levando em consideração a preocupação global com o atendimento ao paciente em meio a esta pandemia, foram abordadas preocupações válidas sobre os meios potenciais de contaminação no consultório odontológico e destacadas as práticas e diretrizes adotadas em diferentes países para minimizar os riscos na assistência odontológica nesta crise global de saúde pública, reforçando assim os desafios da odontologia neste contexto, evidenciando a importância de medidas preventivas rigorosas. Porém, ainda falta padronização dos protocolos de atendimento odontológico e, consequentemente, redução do risco de contágio.

Modification in clic4 expression is associated with p53, tgf-ß, tnf-α and myofibroblasts in lip carcinogenesis

Abstract Chloride intracellular channel-4 (CLIC4) is regulated by p53 and tumor necrosis factor-α (TNF-α), it is linked to the increase of transforming growth factor-β (TGF-β), and myofibroblastic differentiation in skin carcinogenesis. This study analyzed the immunoexpression of CLIC4, p53, TGF-β, TNF-α, and α-SMA in 50 actinic cheilitis (AC) and 50 lower lip squamous cell carcinoma (LLSCC). AC and LLSCC immunoexpression were categorized as score 1 (<5% positive cells), 2 (5-50%) or 3 (>50%). For CLIC4, nuclear and cytoplasmic immunostaining of epithelial cells was considered individually. For morphologic analysis, the World Health Organization criteria were used to epithelial dysplasia grade of ACs, and Bryne grading of malignancy system was applied for LLSCC. Higher nuclear CLIC4 (CLIC4n) and TGF-β were observed in ACs with low-risk of transformation, while cytoplasmic CLIC4 (CLIC4c), p53 and TNF-α were higher in the high-risk cases (p<0.05). In LLSCCs, CLIC4c was higher in cases with lymph node metastasis, advanced clinical stages, and histological high-grade malignancy. p53 expression was higher in high-grade LLSCCs, whereas TGF-β decreased as the clinical stage and morphological grade progressed (p<0.05). ACs showed an increased expression of CLIC4n and TGF-β, while CLIC4c and α-SMA were higher in LLSCCs (p<0.0001). Both lesions showed negative correlation between CLIC4n and CLIC4c, while in LLSCCs, negative correlation was also verified between CLIC4c and p53, as well as CLIC4c and TGF-β (p<0.05). Change of CLIC4 from the nucleus to cytoplasm and alterations in p53, TGF-β, TNF-α, and α-SMA expression are involved in lip carcinogenesis.

Resumo O canal intracelular de cloreto 4 (CLIC4) é regulado pela p53 e fator de necrose tumoral α (TNF-α) e está relacionado ao aumento do fator de crescimento transformador β (TGF-β) e na diferenciação miofibroblástica na carcinogênese cutânea. Este estudo analisou a imunoexpressão de CLIC4, p53, TGF-β, TNF-α e α-SMA em 50 queilites actínicas (QA) e 50 carcinomas de células escamosas de lábio inferior (CCELI). A imunoexpressão da QA e CCELI foram categorizadas em escore 1 (<5% de células positivas), 2 (5-50%) ou 3 (>50%). Para CLIC4, a imunomarcação nuclear e citoplasmática das células epiteliais foi considerada separadamente. Para análise morfológica, foram utilizados os critérios da Organização Mundial da Saúde para a gradação das displasias epiteliais nas QAs, e o sistema de gradação de malignidade de Bryne foi utilizado para os casos de CCELIs. Alta imunoexpressão de CLIC4 nuclear (CLIC4n) e TGF-β foi observada em QA de baixo risco de transformação, enquanto CLIC4 citoplasmática (CLIC4c), p53 e TNF-α foram elevadas nos casos de alto risco (p<0.05). No CCELI, a imunoexpressão de CLIC4c foi maior em caos com metástase linfonodal, estágio clínico avançado e alto grau histológico de malignidade. A expressão de p53 foi elevada em CCELI de alto grau, enquanto o TGF-β diminuiu à medida que o estádio clínico e o grau morfológico progrediram (p<0.05). QAs exibiram uma elevada expressão de CLIC4n e TGF-β, enquanto o CLIC4c e α-SMA foram elevados em CCELIs (p<0.0001). Ambas as lesões mostraram correlação negativa entre CLIC4n e CLIC4c, enquanto nos CCELIs, também se verificou correlação negativa entre CLIC4c e p53, assim como entre CLIC4c e TGF-β (p<0.05). Alteração do CLIC4 do núcleo para o citoplasma e alterações na expressão de p53, TGF-β, TNF-α, e α-SMA estão envolvidas na carcinogênese labial.

Perfil clínico-epidemiológico do carcinoma epidermoide bucal em pacientes adultos jovens dos 20 aos 45 anos: revisão sistemática / Clinical and epidemiological profile of oral squamous cell carcinoma in young adult patients aged 20 to 45 years: systematic review

Objetivo: identificar e descrever o perfil clínico e epidemiológico do carcinoma epidermoide bucal (CEB) em pacientes adultos jovens. Revisão da literatura: realizou-se uma revisão sistemática, utilizando-se como fontes de buscas as bases de dados eletrônicas Lilacs, SciELO, PubMed e Portal de Periódicos Capes, por meio dos descritores: câncer bucal, carcinoma de células escamosas oral, epidemiologia e paciente jovem, nos idiomas português, inglês e espanhol, no período de janeiro de 2003 a janeiro de 2016. Foram identificados 348 artigos, sendo 171 no Portal de Periódicos Capes, 126 no PubMed, 26 no Lilacs e 2 no SciELO. Após análise dos estudos localizados, oito artigos foram selecionados para a presente revisão sistemática. Considerações finais: são necessários mais estudos para a identificação das características clínicas e epidemiológicas do tumor na população em questão, bem como a padronização da faixa etária referente ao termo adulto jovem, visto que esses esclarecimentos podem refletir no seu controle e possibilitar o desenvolvimento de um programa de prevenção primária para o CEB em pacientes jovens. (AU)

Objective: to identify and describe the clinical and epidemiological profile of oral squamous cell carcinoma in young adult patients. Literature Review: a systematic review was performed using the Lilacs, SciELO, PubMed, and Periódicos Capes electronic databases as search sources, through the following descriptors: oral cancer, oral squamous cell carcinoma, epidemiology, and young patient, in English, Spanish, and Portuguese, from January 2003 to January 2016. A total 348 articles were identified, from which 171 were found in Periódicos Capes, 126 in PubMed, 26 in Lilacs, and 2 in SciELO. After analyzing the studies found, eight articles were selected for the present systematic review. Final considerations: further studies are required to identify the clinical and epidemiological characteristics of the tumor in this population and to standardize the age regarding the term young adult, considering these explanations may reflect in its control and allow developing of a primary prevention program for oral squamous cell carcinoma in young patients. (AU)

Síndrome de Eagle: diagnóstico e incidência em uma população brasileira

Objetivo: estabelecer a incidência da síndrome de Eagle(SE) no curso de Odontologia da Universidade deFortaleza durante o período de três anos. Materiais emétodos: foram analisadas 945 radiografias panorâmicas.A avaliação foi realizada por dois examinadoresem ambiente sem iluminação e com a utilização denegatoscópio. Um paquímetro digital foi utilizado paraa mensuração dos casos com alongamento do processoestiloide, sendo considerados alongados os casos apartir de 30 mm. Resultados: das 945 radiografias analisadas,notou-se crescimento do processo estiloide superiora 30 mm em 75 panorâmicas (7,9%), sendo 51(68%) mulheres e 24 (32%) de homens. Em 43 casos(57,3%), o alongamento foi encontrado bilateralmente,em 23 casos (30,7%) foi encontrado apenas no ladoesquerdo e em 9 casos (12%) apenas no lado direito.Os 75 pacientes que possuíam o alongamento do ossoforam submetidos a um questionário semiestruturado e11 pacientes relataram sintomatologia dolorosa, comfrequência variável de surgimento da dor. Uma detalhadaanamnese e um exame físico desses pacientes permitiramo diagnóstico da SE em quatro deles. Conclusão:o trauma na região craniofacial foi o fator etiológicomais evidente nos pacientes diagnosticados com a SE.Os sinais e sintomas inerentes à SE eram semelhantesaos observados nas desordens craniomandibulares, podendoocasionar falsos diagnósticos e tratamentos equivocados.