Comparison Between Radiographs, White and Fluorescent Images in the Diagnosis and Treatment Decisions for Occlusal Caries: An Ex Vivo Study

ABSTRACT Objective: To compare the agreement of images in white light (WL), fluorescence (FL), and digital radiographs (DR), on the diagnosis and treatment decisions for occlusal caries lesions against a micro-CT gold standard. Material and Methods: Ten extracted third molars, with enamel and/or dentin caries (ICDAS 2-4), were included. Occlusal surface images were acquired with an intraoral camera (SoproLife®) in WL and FL modes. DR was obtained using an intraoral X-ray and a semi-direct digital system. A total of 780 images were needed, organized in a template, to be later examined by twenty-six dentists invited to compose the study. The Generalized Estimation Equations model was used to compare the proportions of the correct answers between the three methods and the gold standard. When significant, Bonferroni post-hoc test was used to identify differences (α=5%). Results: Most of the examiners were specialists (76.9%) with 14.5 years of experience. All diagnostic methods were similar and showed low agreement (DR 12.7%, WL 16.5%, and FL 16.5%) compared with gold standard caries diagnostic scores. Regarding treatment decisions, mean agreement for all diagnostic methods was higher (43.2%; p<0.001), and among all methods, WL (48.1%) and FL (51.2%) modes performed better than DR (30.4%, p<0.001). Conclusion: SoproLife® images could help clinicians to propose rational, minimally invasive treatments for occlusal caries lesions.

Relationship between Malocclusion, Bullying, and Quality of Life in Students from Low Social Development Area: A Cross-Sectional Study

ABSTRACT Objective: To analyze the relationship between malocclusion and bullying and its impact on the well-being and quality of life of students from low social development areas. Material and Methods: This cross-sectional study included 243 schoolchildren between 10 and 17 years. Malocclusion was analyzed using Dental Aesthetic Index. Bullying and self-perception of the impact of one's oral condition on quality of life and interpersonal relationships were assessed by questions from National Survey of Schoolchildren's Health and Child Perceptions Questionnaire 11-14 (CPQ11-14). Data were analyzed using the Spearman correlation coefficient and Mann-Whitney tests, considering groups: 10-11, 12-14 and 15-17 years. Results: No correlation was observed between malocclusion and bullying. However, in the 12-14 group, poor correlations were found between malocclusion and the CPQ11-14 (0.226) and between malocclusion and being shy/embarrassed due to oral aspects (0.298). Positive correlations were observed between bullying and the impact on the quality of life in the 10-11 (0.420) and 12-14 (0.425) groups. In the older group, a positive correlation (0.724) was observed between the concern about what others think of their oral health and the impact on their quality of life. Conclusion: There was no evidence of a relationship between malocclusion and bullying. However, the oral conditions negatively affected the interpersonal relationships and the student's quality of life.

Retenção do conhecimento sobre saúde bucal em uma amostra de escolares de Nova Friburgo / Knowledge retention about oral health in a sample of school children from Nova Friburgo

As medidas de orientação para a prevenção da cárie apoiam-se na educação em saúde bucal do paciente. Este trabalho avaliou a retenção do conhecimento sobre saúde bucal em escolares, antes e depois da realização de oficinas educativas. Após a aprovação no comitê de ética em pesquisa (CEP Nº2.987.965) este estudo foi realizado com crianças do ensino fundamental de uma escola pública em Nova Friburgo-RJ. Um questionário sobre práticas de higiene bucal e dieta, e conhecimento sobre as doenças bucais foi desenvolvido e aplicado antes da realização de oficinas educativas em saúde bucal e 15, 30, 60 e 90 dias após. A amostra foi de 136 escolares, 54,4% meninos e 45,6% meninas, com média de idade de 8,7 anos. Antes das oficinas as crianças relataram limpar seus dentes todos os dias (91,2%), pelo menos três vezes ao dia (60,3%), utilizando escova, pasta e fio dental (52,9%); 59,6% das crianças relataram saber o que causava a cárie antes das oficinas; 15 e 30 dias após as oficinas, os percentuais foram de 94,9% e 98,5%, respectivamente (p<0,05), diminuindo para 58,8% após 60 dias. Para a gengivite, apenas 11,8% das crianças relataram saber a causa da doença antes das oficinas; 15 e 30 dias após os percentuais foram de 81,6% e 94,9%, respectivamente, diminuindo para 13,2% após 60 dias. Com base nos resultados observou-se uma diminuição na retenção do conhecimento após 30 dias da realização das atividades educativas, sugerindo que esta população deva receber um programa de educação em saúde bucal de forma continuada.

Guidance measures for the prevention of caries are supported by education in the patient's oral health. This study evaluated the retention of knowledge about oral health in schoolchildren before and after educational workshops. After approval by the Research Ethics Committee (CEP No. 2,987,965) the study was carried out with elementary school children from a public school in Nova Friburgo. A questionnaire on hygiene and dietary practices and knowledge about oral diseases was applied before educational workshops on oral health and 15, 30, 60 and 90 days after. The sample consisted of 136 students, 54.4% boys and 45.6% girls, with an average age of 8.7 years. Before the workshops children reported cleaning their teeth every day (91.2%), at least three times a day (60.3%), using a brush, toothpaste and dental floss (52.9%); 59.6% of children reported knowing what caused decay before participating in the workshops; 15 and 30 days after the workshops the percentages were 94.9% and 98.5%, respectively (p <0.05), decreasing to 58.8% 60 days after. For gingivitis, only 11.8% of children reported knowing the cause of the disease before the workshops; 15 and 30 days after the percentages were 81.6% and 94.9%, respectively, decreasing to 13.2% after 60 days. Based on the results, there was a decrease in knowledge retention after 30 days of educational activities, suggesting that this population should receive an oral health education program on an ongoing basis.

Impact of oral health on the quality of life and personal satisfaction of adolescents from urban and rural areas from a city in brazil: a cross-sectional study

Objective: Evaluate the impact of oral health status on the quality of life and personal satisfaction among adolescents from urban and rural areas, in Nova Friburgo, Brazil. Methods: Adolescents between 11 and 14 years, enrolled in the schools participating in the Health in School Program (HSP) of rural and urban of this city (n = 509), received the consent form for the participation in this study, along with the economic questionnaire to be handed to the responsible. Adolescent´s oral health status was evaluated clinically, through the Decayed, Missing and Filled Teeth (DMFT); pulpal involvement, ulceration, fistula and abscess criteria (PUFA); and Dental Treatment Needs Index (DTNI). The quality of life was measured through the Child Perception Questionnaire (CPQ11-14), while personal satisfaction´s evaluation, through the Subjective Happiness Scale (SHS), both as interview. Statistical tests were performed (Chi-Square; Fisher's exact; Mann-Whitney) with level of significance of 5%. Results: The final sample comprised 161 adolescents. The impact of oral health status on the quality of life of adolescents from both areas was not significantly different, although the aggravation of the oral condition showed a tendency to worse the quality of life. Similarly, there was no relation of the oral status with personal satisfaction, without differences between the groups. It was observed that rural adolescents presented better quality of life (p<0.010), while the urban ones had higher degree of personal satisfaction (p<0.001). Conclusion: Oral health status had a negative impact on the quality of life, but had no relation to personal satisfaction, regardless of the demographic area.

Objetivo: Avaliar o impacto do estado de saúde bucal na qualidade de vida e na satisfação pessoal de adolescentes das áreas urbana e rural de Nova Friburgo, Brasil. Métodos: Adolescentes entre 11 e 14 anos, matriculados nas escolas participantes do Programa Saúde na Escola (PSE) da zona rural e urbana desta cidade (n = 509), receberam o Termo de Consentimento Livre e Esclarecido para a participação neste estudo,juntamente ao questionário econômico a ser entregue para o responsável. O estado de saúde bucal do adolescente foi avaliado clinicamente, por meio dos índices Cariados, Perdidos e Obturados (CPOD); critérios de envolvimento pulpar, ulceração, fístula e abscesso (PUFA); e Índice de Necessidades de Tratamento Odontológico (INTO). A qualidade de vida foi mensurada por meio do Child Perception Questionnaire (CPQ11- 14), enquanto a avaliação da satisfação pessoal, por meio da Subjective Happiness Scale (SHS), ambos na forma de entrevista. Foram realizados testes estatísticos (Qui-Quadrado; Exato de Fisher; Mann-Whitney) com nível de significância de 5%. Resultados: A amostra final foi de 161 adolescentes. O impacto do estado de saúde bucal na qualidade de vida dos adolescentes de ambas as áreas não foi significativamente diferente, embora o agravamento da condição bucal tenha apresentado tendência a piorar a qualidade de vida. Da mesma forma, não houve relação da condição oral com a satisfação pessoal, sem diferenças entre os grupos. Observou-se que os adolescentes rurais apresentaram melhor qualidade de vida (p<0,010), enquanto os urbanos apresentaram maior grau de satisfação pessoal (p<0,001). Conclusão: O estado de saúde bucal teve impacto negativo na qualidade de vida, mas não teve relação com a satisfação pessoal, independente da área demográfica.

Efficacy of resin infiltration of proximal caries in primary molars: 1-year follow-up of a split-mouth randomized controlled clinical trial.

OBJECTIVE: The main purpose of this split month, randomized, controlled clinical trial was evaluate the efficacy of caries infiltration in controlling the progression of non-cavitated proximal lesions in primary molars. Anxiety and time required for the caries infiltration was also evaluated. MATERIALS AND METHODS: Fifty healthy children, 5 to 9 years, presenting two primary molars with proximal caries lesions (1/2 of the enamel or outer 1/3 of dentin), were included. Lesions were randomly allocated to the test group (fluoridated toothpaste + flossing + infiltration) or to the control group (fluoridated toothpaste + flossing). Caries risk was based on the Cariogram model. The main outcome after 1-year radiographic follow up was assessed by an independent blinded examiner A facial image scale (FIS) was applied to assess dental anxiety and time required to perform the infiltration was recorded. RESULTS: Of the sample, 92.9% corresponded to high or medium caries risk. In 42 patients (1-year follow up), caries progression was observed in 11.9% (5/42) of the test lesions compared with 33.3% (14/42) of the control lesions (p < 0.05). Five control and three test lesions progressed to the middle 1/3 of dentin and were restored. No side effects were observed. Anxiety was both low before and after the treatment, and mean time required for the infiltration was 11.29 min (± 1.16 min). CONCLUSIONS: Caries infiltration of proximal caries lesions in primary molars is significantly more efficacious than standard therapy alone (fluoride toothpaste + flossing). CLINICAL RELEVANCE: Caries infiltration is an applicable and well-accepted method be used in children, representing a promising micro-invasive approach.

Oral findings in a family with Tuberous sclerosis complex.

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder with a multisystemic character that may present alterations in multiple organ systems, including oral manifestations. This case report describes a family (mother and two sons) with TSC that underwent a multidisciplinary approach, emphasizing their oral manifestations and highlights the adequate approach taken. The children presented many and distinct features of TSC in different systems; however the family revealed similar oral manifestations. The oral findings were dental enamel pits on permanent teeth and spread gingival fibromas on both jaws. The dental planning was the same for all three patients and included guidelines on oral hygiene and dietary habits, fluoride therapy and a preventive approach through six-month reevaluations. In multisystemic disorders, early multidisciplinary action is vital to provide comprehensive care and reduce or even prevent complications from the condition, thus ensuring the patient's quality of life.

Infiltração em lesões cariosas proximais em molares decíduos: ensaio clínico randomizado controlado / Infiltration of proximal carious lesions in primary molars: randomized controlled clinical trial

O objetivo do estudo foi avaliar a eficácia da técnica de infiltração em cárie no controle da progressão de lesões cariosas proximais não cavitadas em molares decíduos. Foi realizada uma revisão sistemática/metanálise sobre eficácia do selamento de lesões cariosas proximais não cavitadas no controle da doença. Como estudo de método, foi verificada a influência do uso de filtros radiográficos digitais (FRD) na concordância entre examinadores em relação à detecção de lesões cariosas proximais em molares decíduos. Um ensaio clínico randomizado e controlado foi desenvolvido para avaliar a eficácia da infiltração em cárie (Icon®, DMG, Hamburgo, Alemanha) na progressão de lesões cariosas proximais em molares decíduos. Além disso, avaliar a ansiedade das crianças em relação à técnica, e o tempo necessário. Crianças (n=50) saudáveis, entre 5 e 9 anos, apresentando pelo menos 2 molares decíduos com lesões cariosas proximais detectadas na radiografia (1/2 interna do esmalte ou 1/3 externo da dentina) participaram do estudo. As lesões foram randomicamente alocadas em um dos grupos: teste (controle de biofilme com pasta fluoretada e fio dental + técnica da infiltração-Icon®) e controle (controle de biofilme com pasta fluoretada e fio dental). O risco de cárie foi baseado no Cariograma. O principal desfecho foi a progressão radiográfica de cárie, após 1 ano de acompanhamento, pela análise pareada, avaliada por um examinador externo e cego. A ansiedade das crianças foi avaliada por meio de uma Escala de imagem facial (EIF) e o tempo necessário para a técnica foi registrado. Com relação à revisão sistemática/metanálise, concluiu-se que o selamento/infiltração de lesões proximais não cavitadas parece ser eficaz no controle da progressão da cárie a curto e médio prazo. Em relação aos FRD, os resultados mostraram que os mesmos não aumentaram a concordância interexaminadores em relação à detecção de cárie proximal em molares decíduos. Em relação ao ensaio clínico, 94% da amostra corresponderam a médio ou alto risco de cárie. Em um total de 20 pacientes avaliados após 1 ano, observou-se progressão de cárie em 5% (1/20) das lesões teste, em comparação a 25% (5/20) das lesões controle (p=0.09). Duas lesões do grupo controle progrediram para o 1/3 médio da dentina, tendo sido restauradas. Clinicamente, não houve progressão para cavidade. Biofilme e sangramento gengival estavam presentes na maioria dos sítios proximais (teste e controle), no início e com 1 ano (p>0.05). Não foi observado efeito colateral. Não houve relação entre risco de cárie no início e progressão de cárie (p>0.05). De acordo com a EIF, o nível de ansiedade foi baixo, antes e após a infiltração. A média de tempo para a infiltração foi 11,29 min (±1,16). Os resultados indicam que a técnica de infiltração em cárie é um método aplicável, bem aceito em crianças e eficaz no controle de lesões cariosas proximais em molares decíduos, uma vez que as lesões teste progrediram menos que as lesões controle. (AU)

The purpose of the present study was to evaluate the efficacy of caries infiltration of proximal caries lesions in primary molars. It was performed a systematic review and meta-analysis in relation to the efficacy of sealing non-cavitated proximal caries in controlling the disease. As a study method, to analyze the influence of digital filters (DF) on the agreement between examiners regarding the detection of proximal caries lesions in primary molars. A split-mouth randomized controlled clinical trial was performed with the main purpose to evaluate the efficacy of caries infiltration (Icon®, DMG, Hamburgo, Germany) in controlling the progression of noncavitated proximal lesions in primary molars. Besides, to evaluate dental anxiety and the time required to the caries infiltration procedure. Healthy children (n=50), ranged from 5 to 9 years, presenting at least two primary molars with proximal lesion detected on the radiographs (radiolucency involving the 1/2 of the enamel or in the outer 1/3 of dentin) were included on the study. Lesions were randomly allocated for one of the two groups: test group (resin infiltration-Icon®) and control group (flossing). Children´s caries risk was based on the Cariogram model. The main outcome after 1-year of radiographically caries progression by pair-wise reading was assessed by a blinded independent examiner. A Facial image scale (FIS) was applied before and after the caries infiltration to assess the dental anxiety and the time required was recorded. The majority of the sample (94%) corresponded to high or medium caries risk. In 20 patients assessed after 1-year follow-up, caries progression was observed in 5% (1/20) of the test lesions, compared with 25% (5/20) of the control lesions (p=0.09). Two lesions from the control group progressed to radiolucency in the middle 1/3 of dentin, and were restored. Clinically, no progression to cavitation was observed in the entire sample. Plaque and gingival bleeding were present in most of the proximal selected sites (test and control) at baseline and also at the recall (1-year) (p>0.05). No unwanted side-effects were observed. The relation between patient´s caries risk at the baseline and caries progression was not statistically significant (p>0.05). According to the FIS, the level of anxiety was low both before and after the treatment. The mean time required for the infiltration was 11.29 min (± 1.16 min). The systematic review/meta-analysis concluded that sealing non-cavitated proximal caries lesions, both in primary and permanent teeth, seems to be effective in controlling caries progression in the short and medium term. In relation to the use of DF, it did not increase the inter-examiner agreement regarding the detection of proximal caries in primary molars. The results of the clinical trial indicate that caries infiltration is an applicable and well-accepted method to be used in children and efficacious in controlling proximal caries lesions in primary molars, since test lesions progressed less than control lesions. (AU)

Efficacy of chemomechanical caries removal in reducing cariogenic microbiota: a randomized clinical trial.

The aim of this study was to compare the efficacy of chemochemical methods (Carisolv™ and Papacárie®) versus the manual method (excavators) in reducing the cariogenic microbiota in dentine caries of primary teeth. Forty-six healthy children (5 to 9 years old) having at least one primary tooth with a cavitated dentine carious lesion were included in the study. The teeth presented no clinical or radiographic signs of pulpal involvement. The sample of 74 teeth was randomly divided into three different groups: Papacárie® (n = 25), Carisolv™ (n = 27) and Manual (n = 22). Samples of carious and sound dentine were collected with sterile excavators before and after caries removal in the three groups. The dentine samples were transferred to glass tubes containing a 1mL thioglycollate medium used as a carrier and enriched for microbiological detection of mutans streptococci and Lactobacillus spp, after incubation for 6h at room temperature. The minimum detection value for colony forming units (CFU) was 3.3 x 102 CFU/ml, and the results were converted into scores from 0 to 4. A significant difference was observed in relation to the microbiological scores before and after caries removal for all methods (Wilcoxon test; p < 0.001). The use of chemomechanical methods for caries removal did not improve the reduction of cariogenic microorganisms in dentine caries lesions, in comparison with manual excavation.

Is non-cavitated proximal lesion sealing an effective method for caries control in primary and permanent teeth? A systematic review and meta-analysis.

OBJECTIVES: The aim of this study was to perform a systematic review and meta-analysis on the effectiveness of sealing non-cavitated proximal caries lesions in primary and permanent teeth. DATA: Only controlled clinical trials and randomized controlled clinical trials that evaluated the effectiveness of sealing on non-cavitated proximal caries with a minimum follow-up of 12 months were included in the study. The primary outcome should be arrestment/progression of proximal caries evaluated by bitewing radiographs. A risk of bias evaluation based on the Cochrane Collaboration common scheme for bias was carried out for each study. The meta-analysis was performed on the studies considered low risk of bias and with pair-wise visual reading results through RevMan software. SOURCES: A comprehensive search was performed in the Systematic Electronic Databases: Pubmed, Cochrane Library, Scopus, IBI Web of Science, Lilacs, SIGLE, and on website Clinical trials.gov, through until June 2013. STUDY SELECTION: From 967 studies identified, 10 articles and 3 studies with partial results were assessed for eligibility. However three articles were excluded and our final sample included 10 studies. According to the risk of bias evaluation, six studies were considered "high" risk of bias, and four "low" risk of bias. The forest plot of the meta-analysis showed low heterogeneity (I(2)=29%) and a favourable outcome for the Infiltrant. The chance of caries progression when this technique was used was significantly lower (p=0.002) compared with Placebo. CONCLUSION: Our results suggest that the technique of sealing non-cavitated proximal caries seems to be effective in controlling proximal caries in the short and medium term. Further long-term randomized clinical trials are still necessary to increase this evidence. CLINICAL SIGNIFICANCE: Contemporary dentistry is focused in minimally invasive approaches that prevent the destruction of sound dental tissues next to carious lesions. This paper searches for evidence of the efficacy of sealing/infiltrating non-cavitated proximal caries in arresting caries progression both in permanent and primary teeth.

Caries diagnosis under the focus of thee vidence-based dentistry

Any dental clinician, specially the pediatric dentist, needs to have knowhow about the available diagnostic procedures for dental caries detection and understand the effectiveness of these procedures in order to give appropriate weight to the result in clinical decision taking. The purpose of the present paper is to verify the status of the literature about the procedures available in dental caries diagnosis, in pediatric dentistry,using the evidence-based dentistry methodology. This study was carried out in two phases. The first one consisted in a search for texts related to the theme, in English language and indexed in the MEDLINE database,as well as a review of some Epidemiology books. After that, all abstracts of the papers obtained through the key words provided by the Medical Subject Headings (MeSH), were read and classified according to their relevance and pertinence. The journal and the countries that most published relevant and pertinent papers were Caries Research and theUnited Kingdom (UK) and United States of America (USA), respectively.No pertinent meta-analysis has been made until the present moment.

Todo cirurgião-dentista, principalmente o odontopediatra, necessita ter conhecimento suficiente quanto aos métodos de diagnóstico disponíveis para a detecção de cárie dentária, além de entender a efetividade desses métodos para dar apropriado peso ao resulta donos momentos de decisão clínica. O objetivo deste trabalho é verificar o que diz a literatura sobre os procedimentos utilizados no diagnóstico da cárie dentária, em odontopediatria, por meio da metodologia proposta pela Odontologia baseada em evidências (OBE). Este estudofoi dividido em duas etapas. Na primeira, foi realizada uma busca nabase de dados MEDLINE de textos relacionados ao assunto, em língua inglesa, e revisão de alguns livros de epidemiologia. Em seguida, todos os resumos dos trabalhos apresentados pela base de dados, a partir das palavras-chave indicadas pelo Medical Subject Headings (MeSH),foram lidos e classificados quanto à relevância e pertinência ao tema.O periódico que mais publicou artigos relevantes foi o Caries Research,e os países que mais pesquisaram com a metodologia da OBE foram o Reino Unido e os Estados Unidos. Nenhuma metanálise pertinente ao tema foi realizada até o presente momento.

Diagnóstico de cárie sob o enfoque da odontologia baseada em evidências / Caries diagnosis under the focus of the evidence-based dentistry

Todo cirurgião-dentista, principalmente o odontopediatria, necessita ter conhecimento suficiente quanto aos métodos de diagnóstico disponíveis para a detecção de cárie dentária, além de entender a efetividade desses métodos para dar apropriado peso ao resultado nos momentos de decisão clínica. O objetivo deste trabalho é verificar o que diz a literatura sobre os procedimentos utilizados no diagnóstico da cárie dentária, em odontopediatria, por meio da metodologia proposta pela Odontologia baseada em evidências (OBE). Este estudo foi dividido em duas etapas. Na primeira, foi realizada uma busca na base de dados MEDLINE de textos relacionados ao assunto, em língua inglesa, e revisão de alguns livros de epidemiologia. Em seguida, todos os resumos dos trabalhos apresentados pela base de dados, a partir das palavras-chave indicadas pelo Medical Subject Headings (MeSH), foram lidos e classificados quanto à relevância e pertinência ao tema. O periódico que mais publicou artigos relevantes foi o Caries Research, e os países que mais pesquisaram com a metodologia da OBE foram o Reino Unido e os Estados Unidos. Nenhuma metanálise pertinente ao tema foi realizada até o presente momento

Any dental clinician, specially the pediatric dentist, needs to have know-how about the available diagnostic procedures for dental caries detectionand understand the effectiveness of these procedures in order to give appropriate weight to the result in clinical decision taking. The purpose of the present paper is to verify the status of the literature about the procedures available in dental caries diagnosis, in pediatric dentistry,using the evidence-based dentistry methodology. This study was carried out in two phases. The first one consisted in a search for texts related to the theme, in English language and indexed in the MEDLINE database,as well as a review of some Epidemiology books. After that, all abstractsof the papers obtained through the key words provided by the Medical Subject Headings (MeSH), were read and classified according to their relevance and pertinence. The journal and the countries that most published relevant and pertinent papers were Caries Research and the United Kingdom (UK) and United States of America (USA), respectively. No pertinent meta-analysis has been made until the present moment

Remoção químico-mecânica da cárie: evidências atuais / Chemo-mechanical caries removal: current evidences

Ao longo dos anos, a Odontologia Restauradora vem aprimorando as técnicas de remoção do tecido cariado, visando facilitar a rotina clínica. Um desses avanços foi a introdução da remoção químico-mecânico da cárie. O presente trabalho tem como objetivo apresentar dois produtos atualmente disponíveis para a remoção químico-mecânica da cárie, bem como comparar suas técnicas. Os produtos disponíveis são o Carisolv e o Papacárie®, que não requerem o uso de anestesia local e instrumentos rotatórios. Eles diferem na origem e composição. As evidências científicas atuais conferem ao Carisolv maior visibilidade internacional em razão das pesquisas já publicadas, ao passo que o Papacárie® necessita de um maior número de pesquisas para comprovar sua efetividade prática clínica