Prevalence of Bruxism in Children and Adolescents with Cerebral Palsy: Systematic Review and Meta-analysis.

AIMS: To perform a systematic review and meta-analysis compiling data on the prevalence of bruxism in children and adolescents with cerebral palsy. METHODS AND RESULTS: Searches were carried out in PubMed/Medline, Web of Science, and Scopus databases to identify the articles published by February 2023. Two independent reviewers, and in duplicate, employed a two-stage process to select publications. The same two reviewers performed the data extraction. Studies were included when the following eligibility criteria were met: performed in children and/or adolescents with cerebral palsy and reporting bruxism. Potentially eligible studies were read in full and excluded that: not presented numerical data on the prevalence of bruxism; not reported how the bruxism was assessed; not reported data about the cerebral palsy; and not an observational study. The risk assessment of bias was assessed by the Newcastle- Ottawa Scale. After reading the titles and abstracts of the 358 identified articles, eight articles from 1966 to 2020 were included. The main reason for not including the studies was not to report data about bruxism (59.3%), and 44.5% were excluded for not reporting data from patients with cerebral palsy. The studies were carried out in schools, university hospitals, or centers for patients with special needs (Brazil, the United States, and Egypt). The pooled prevalence of bruxism in children and adolescents with cerebral palsy was 46% (95%CI: 0.38-0.55) after removing one study. CONCLUSION: The pooled prevalence of bruxism in children with cerebral palsy can be considered high since almost half of the studied population is affected by this condition. PROSPERO #CRD42021225781.

Associated factors and treatment options for sleep bruxism in children: an umbrella review.

Data on clinical management options for sleep bruxism in the primary dentition are inconclusive. This umbrella review aimed to synthesize the available evidence from systematic reviews (SRs) on the associated factors and treatment approaches for clinical management of sleep bruxism in children. A search was conducted in the MEDLINE/PubMed, Web of Science, Embase, and OpenGrey databases up to March 2022. SRs published on sleep bruxism in children containing data on associated factors or treatment outcomes were included. The AMSTAR-2 tool was used to assess the methodological quality of SRs. The search identified 444 articles, of which six were included. Sleep conditions, respiratory changes, personality traits, and psychosocial factors were the associated factors commonly identified. Treatments included psychological and pharmacological therapies, occlusal devices, physical therapy, and surgical therapy. All SRs included presented a high risk of bias. Overlapping of the included studies was considered very high. The best evidence available to date for the management of sleep bruxism in children is based on associated factors, with sleep duration and conditions, respiratory changes, as well as personality traits and psychosocial factors being the most important factors commonly reported by studies. However, there is currently insufficient evidence to make recommendations for specific treatment options.

Associated factors and treatment options for sleep bruxism in children: an umbrella review

Abstract Data on clinical management options for sleep bruxism in the primary dentition are inconclusive. This umbrella review aimed to synthesize the available evidence from systematic reviews (SRs) on the associated factors and treatment approaches for clinical management of sleep bruxism in children. A search was conducted in the MEDLINE/PubMed, Web of Science, Embase, and OpenGrey databases up to March 2022. SRs published on sleep bruxism in children containing data on associated factors or treatment outcomes were included. The AMSTAR-2 tool was used to assess the methodological quality of SRs. The search identified 444 articles, of which six were included. Sleep conditions, respiratory changes, personality traits, and psychosocial factors were the associated factors commonly identified. Treatments included psychological and pharmacological therapies, occlusal devices, physical therapy, and surgical therapy. All SRs included presented a high risk of bias. Overlapping of the included studies was considered very high. The best evidence available to date for the management of sleep bruxism in children is based on associated factors, with sleep duration and conditions, respiratory changes, as well as personality traits and psychosocial factors being the most important factors commonly reported by studies. However, there is currently insufficient evidence to make recommendations for specific treatment options.

Condiciones periodontales asociadas con hiposalivacíon en pacientes con síndrome de Down / Condições periodontais associadas com hipossalivação em pacientes com síndrome de Down / Periodontal conditions associated with hiposalivation in patients with Down syndrome

El curso de enfermedades periodontales en el Síndrome de Down (SD) es más temprano y agresivo y está mediado por numerosos factores, como los hábitos de higiene bucal, el perfil inflamatorio y las alteraciones salivales. Objetivo: Evaluar cómo la hiposalivación y otros parámetros salivales pueden influir en las enferme-dades periodontales en los pacientes con síndrome de Down en diferentes edades. Materiales y métodos: Una muestra compuesta por 124 pacientes (Grupo A - 62 síndrome de Down; Grupo B - 62 pacientes no sindrómi-cos) de 6 a 52 años fue excedida para evaluar los parámetros salivales (flujo salival, pH y capacidad tampón) y enfermedades periodontales (índice de placa, sonda de sangrado, profundidad de sondeo y otros). Además, se recopiló información sobre salud general y hábitos de higiene oral. Resultados: El grupo A presentó un alto índice de placa, baja capacidad tampon y bajo flujo salival. Se encontró una alta prevalencia de enfermedades periodontales en pacientes con SD y una correlación entre el flujo salival bajo y la gravedad de la enferme-dad periodontal (correlación = -0,27, p = 0,002). Estos datos revelan el impacto sobre el indicador salival y la enfermedad periodontal. Conclusión: Los pacientes con SD e hiposalivación presentan un mayor riesgo de desarrollar enfermedad periodontal.

The periodontal diseases course in Down syndrome (DS) are earlier and aggressive and are mediated by nume-rous factors, such as oral hygiene habits, inflammatory profile and salivary alterations. Objective: To evaluate how the hyposalivation and other salivary parameters can influence a periodontal disease on patients with Down syndrome in different ages. Material and methods: A sample composed by 124 patients (Group A ­ 62 Down syndromes; Group B ­ 62 Non-syndromic patient) from 6 to 52 years old was excessed to evaluate the salivary parameters (salivary flow, pH and buffer capability) and periodontal diseases (plaque index, bleeding probing, probing depth and others). Also, was collected information about general health and oral hygiene habits. Re-sults: The Group A exhibited high rate of plaque, low buffer capacity and low salivary flow. It was found a high prevalence of periodontal diseases in DS patients and a correlation among the low salivary flow and the seve-rity of the periodontal disease (correlation = -0,27, p = 0,002). These data reveal the impact upon the salivary indicator and the periodontal disease. Conclusion: Patients with DS and hyposalivation present a greater risk to developing periodontal disease.

O curso de doenças periodontais na Síndrome de Down (SD) é precoce e agressivo e mediado por inúmeros fatores, como hábitos de higiene bucal, perfil inflamatório e alterações salivares. Objetivo: Avaliar como a hipossalivação e outros parâmetros salivares podem influenciar as doenças periodontais em pacientes com síndrome de Down em diferentes idades. Métodos: Amostra composta por 124 pacientes (Grupo A - 62 com Síndrome de Down; Grupo B - 62 não sindrômicos) com 6 a 52 anos de idade foi excedida para avaliar os parâ-metros salivares (fluxo salivar, pH e capacidade tampão) e doenças periodontais (índice de placa, sangramento sondagem, profundidade de sondagem e outros). Além disso, foram coletadas informações sobre saúde geral e hábitos de higiene bucal. Resultados: O grupo A apresentou alto índice de placa, baixa capacidade tampão e baixo fluxo salivar. Foi encontrada uma alta prevalência de doenças periodontais em pacientes com SD e uma correlação entre o baixo fluxo salivar e a gravidade da doença periodontal (correlação = -0,27, p = 0,002). Esses dados revelam o impacto sobre o indicador salivar e a doença periodontal. Conclusão: Pacientes com SD e hipossalivação apresentam maior risco de desenvolver doença periodontal.

Oral health status of children and young adults with autism spectrum disorders: systematic review and meta-analysis.

BACKGROUND: Individuals with special needs are often affected by oral disorders such as dental caries and periodontal disease. Current data regarding prevalence of these conditions in individuals with autism spectrum disorders (ASD) are controversial. AIM: To conduct a systematic review and meta-analysis to verify the prevalence of dental caries and periodontal disease in individuals with ASD, especially children and young adults. DESIGN: Searches were conducted through MEDLINE/PubMed, Web of Science, and Scopus databases in December 2015. Studies were included if fulfilled the following eligibility criteria: to evaluate the oral health status of individuals with ASD; to be an observational study; and to assess the prevalence of dental caries and/or periodontal disease. Meta-analyses were conducted considering prevalence of dental caries and periodontal disease in individuals as outcome. RESULTS: Search strategy identified 928 potentially relevant articles and seven of them were included in this review. All included studies reported dental caries prevalence, and the pooled prevalence was 60.6% (95% CI: 44.0-75.1). Moreover, only three studies showed prevalence of periodontal disease, resulting in pooled prevalence of 69.4% (95% CI: 47.6-85.0). CONCLUSION: Prevalence of dental caries and periodontal disease in children and young adults with ASD can be considered as high, pointing to the need for oral health policies focused on these individuals.

Indicadores salivares e o risco de cárie na Síndrome de Down utilizando o software Cariogram® / Salivary indicators and the caries risk in Down Syndrome using Cariogram software

O objetivo deste estudo foi analisar o risco de cárie em indivíduos com Síndrome de Down (SD) utilizando o Software Cariogram®, associando aos indicadores salivares. Participaram do estudo 124 pacientes, entre 6-52 anos, 62 indivíduos SD e 62 indivíduos controles sem a síndrome. Foram recolhidos dados sobre dieta, uso de flúor, pH salivar, capacidade tampão e contagem de Streptococcus mutans. Os resultados mostraram que os indivíduos SD apresentaram maior índice de placa, capacidade tampão e fluxo salivar reduzidos. A hipossalivação mostrou uma associação moderada com índice CPOD e índice de placa. Na análise Cariogram® verificou-se alto risco de cárie nestes pacientes, e dada a importância e facilidade deste método de diagnóstico, sugerimos que seu uso seja ampliado como uma ferramenta importante para facilitar o controle da cárie em indivíduos SD.

The aim of this study was to analyze the caries risk in Down Syndrome individuals (SD) using the Cariogram® software and salivary parameters. We considered a sample of 124 patients aged 6-52 years, 62 with SD and 62 without the syndrome (controls). Data were also collected on diet, use of fluoride, saliva pH, buffer capacity and Streptococcus mutans count. The results were that the SD patients had a higher plaque index, lower buffering capacity and reduced salivary flow. A higher prevalence of hyposalivation, showing a moderate association with DMFT and plaque index. In the Cariogram® analysis we found a high risk of caries in these patients, and given the importance and ease of this method of diagnosis, we suggest that its use be established as an important tool in facilitating the control of caries in Down syndrome individuals.

Identification of microorganisms in biofluids of individuals with periodontitis and chronic kidney disease using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

RATIONALE: Chronic kidney disease (CKD) and periodontitis (PD) are important health issues. There is a large variety of microorganisms related to the pathogenesis of periodontitis, and optimising the time and the cost of laboratory assays to detect these organisms is highly valuable in the medical field. METHODS: Bacteria were isolated from saliva and oral biofilm of 30 adolescents and young adults with definite medical and dental diagnosis of CKD and PD, respectively, and proteins were extracted for microorganism identification by means of the matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOFMS) technique. RESULTS: The results showed that the most incident microorganisms were Actinomyces dentalis (43%), Acinetobacter ursingi (60%), Aggregatibacter actinomycetencomitans (60%), Corynebacterium argentoctens (63%), Staphylococcus aureus (93%), Streptococcus salivarius (97%) and Tannerella forsythensis (43%). The analysis of oral biofilm showed higher incidences for Actinomyces dentalis (33%), Acinetobacter ursingi (50%), Aggregatibacter actinomycetencomitans (50%), Corynebacterium argentoctens (70%), Pseudomonas aeruginosa (40%), Staphylococcus aureus (73%) and Streptococcus salivarius (87%). CONCLUSIONS: Based on these results, we concluded that the MALDI Biotyper protocol proves useful as a rapid and reliable assay for distinguishing different microorganisms possibly related to CKD and PD. Copyright © 2016 John Wiley & Sons, Ltd.

Estudo do metaboloma salivar e sua associação com a doença periodontal em pacientes com síndrome de Down / Saliva metabolome in patients with Down syndrome and its association with periodontal disease

Os pacientes com Síndrome de Down (SD) possuem grande incidência de doença periodontal (DP), caracterizada por um curso precoce e com maior severidade. O estudo de metaboloma pode contribuir para o entendimento deste curso da doença, identificando possíveis metabólitos como biomarcadores nestes indivíduos. Para entender o perfil metabolômico dos indivíduos com síndrome de Down e a sua relação com a doença periodontal, realizamos a identificação de metabólitos salivares de adolescentes e adultos jovens, entre 12 e 21 anos, ambos os gêneros. Foram coletados dados sobre o estado geral de saúde e realizados exames clínicos bucais, como índice de higiene oral simplificado, sangramento e profundidade de sondagem. Para a análise do metaboloma foi coletada amostra de saliva não estimulada, analisadas por meio de cromatografia gasosa acoplada á espectrometria de massas. Saliva e fluido crevicular gengival também foram coletados para identificação microbiana através do MALDI-TOF. Os dados encontrados foram submetidos a análise estátisca por meio da Análise dos Componentes Principais (PCA) e quantificação relativa dos metabólitos foi avaliada por testes não paramétricos, Mann-Whitney

e Kruskal-Wallis. Foi possível observar através dos modelos de PCA separação dos indivíduos com SD e controles, independente da doença periodontal. A quantificação relativa revelou maiores níveis de glicina, lprolina, l-leucina, l-serina, ácido palmítico, ácido pentanóico, ácido tetradecanóico, tirosina e l-fenilalanina nos grupos SD quando comparados aos controles. Controles com DP também apresentaram níveis elevados de glicina, l-alanina, l-serina e manopiranose quando comparados com controles saudáveis. A microbiota de indivíduos com SD apresentous diferenças siginificantes em relação aos individuos controles, principalmente para Rothia dentocariosa, Staphylococcus epidermidis, Tannerella forsythia quando avaliado a saliva e A. Actinomycetemcomitans, Micrococcus luteus, Rothia aeria, Treponema denticola no fluido crevicular gengival. Em conclusão, o perfil metabolômico impresso nos indivíduos com SD difere significativamente dos indivíduos controles, independente da doença periodontal. Entretanto, os metabólitos que diferenciam indivíduos controles com e sem DP, apresentam-se elevados em todos indivíduos com SD, promovendo novos "insights" para o perfil metabólico relacionado a DP na SD.

Down Syndrome (DS) patients have a high incidence of periodontal disease (PD), characterized by an early course and greater severity. The metabolome study may contribute to the understanding of the disease course, identifying possible metabolites as biomarkers in these individuals. To understand the metabolomic profile of the DS and their relationship with PD, we conducted the identification of salivary metabolites of adolescents and young adults between 12 and 21 years, both genders. Data were collected on general health and was performed oral clinical examination, as the IHOS, bleeding index and probing depth. For metabolome analysis was collected unstimulated saliva sample, analyzed by gas chromatography coupled to mass spectrometry. Saliva and gingival crevicular fluid were also collected for microbial identification by MALDI-TOF. Data were submitted to analysis-statistic by PCA and relative quantification

of metabolites was evaluated by Mann-Whitney and Kruskal-Wallis tests. It can be observed through the PCA models separation of DS groups and controls groups, regardless of periodontal disease. Relative quantification showed higher levels of glycine, L-proline, L-leucine, L-serine, palmitic acid, pentanoic acid, tetradecanoic acid, tyrosine and L-phenylalanine in the SD groups when compared to controls groups. Controls with PD also showed high levels of glycine, L-alanine, L-serine and mannopyranose compared with healthy controls. The microbiota of individuals with DS groups show significant differences compared to control groups, especially for Rothia dentocariosa, Staphylococcus epidermidis, Tannerella forsythia when evaluated saliva and A. actinomycetemcomitans, Micrococcus luteus, Rothia aeria, Treponema denticola in gingival crevicular fluid. In conclusion, the printed metabolomic profile in individuals with Down syndrome differs significantly from control subjects, regardless of periodontal disease. However, the metabolites that distinguish controls group with and without PD, show up high in all DS individuals, promoting new "insights" to the metabolic profile related to PD in DS.

Manifestaciones orales del síndrome del cromosoma 18 en anillo / Oral manifestations in chromosome 18 ring

El síndrome del cromosoma 18 en anillo es un desorden inusual cromosómico con varios cambios generalizados en el cuerpo y boca. Este artículo presenta el reporte del caso de un niño con síndrome del cromosoma 18 en anillo con retardo mental. Esta combinación raramente estudiada, presenta cambios generales y bucales predominantes y retención prolongada de dientes deciduos. El odontólogo debe estar preparado para detectar estos hallazgos en este tipo de pacientes y tratarlos precozmente proporcionando mejoras en su calidad de vida.

Ring chromosome 18 syndrome is a rare chromosomal disorder, with many changes in the general body and mouth. This article reports the case of a child with the syndrome ring chromosome 18 and mental retardation. This combination rarely studied shows oral and general predominant changes and prolonged retention of deciduous teeth. The dentist must be prepared to recognize these findings and treat them at early stages to promote improvements in their quality of life.

Prevalência de cárie em grupos distintos de pacientes com necessidades especiais / Prevalence af dental caries in differents graups af patients with special needs

A prevenção da cárie para pessoas com deficiência é um problema desafiador na Odon¬tologia, verificando-se altas taxas de prevalência para a doença, falta de tratamento con¬servador e higiene bucal precária. O objetivo deste estudo foi avaliar a prevalência de cárie através do CPO-D e ceo-d em pacientes com distintas deficiências. Participaram 130 pa¬cientes, de ambos os gêneros, na faixa etária de 6 a 52 anos, divididos em grupos segundo a patologia de base, constituindo o grupo 1: 45 individuos com Síndrome de Down; grupo 2: 43 indivíduos com Paralisia Cerebral; grupo 3: 42 indivíduos com Deficiência Mental. O grupo com deficiência mental mostrou maior prevalência de CPO-D, quando comparados aos outros grupos, os pacientes com síndrome de Down demonstraram menor prevalência de cárie, dentes obturados e perdidos em relação às outras síndromes.

The caries prevention for people with disabilities is a challenging problem in dentistry, ve¬rifying high prevalence rates for this disease, the lack of conserva tive treatment and poor oral hygiene. The aim of this study was to evaluate the prevalence of caries through the DMFr and dmft in patients with different disabilities. The sample consisted of 130 patients of both gen¬ders, aged 6 to 52 years, divided into groups according to underlying pathology, constituting the SD group: 45 individuais with Down syndrome; CP group: 43 individuais with Cerebral Palsy ; DM group: 42 individuais with mental retardation. The group with mental retardation had a higher prevalence of DMFT, compared to other groups, patients with Down syndrome showed a lower prevalence of caries, fillings and missing teeth in relation to other syndromes.

Use of photodynamic therapy as an adjuvant to periodontal treatment in patients with Down syndrome: case report / Uso da terapia fotodinâmica como coadjuvante ao tratamento periodontal no paciente com síndrome de Down: relato de caso

Periodontitis is an inflammatory disease induced by bacteria in plaque biofilm on the surface subgingival. The inflammation leads to pocket formation in the gingival tissue, attachment loss, bone destruction and ultimately possible tooth loss. The prevalence of periodontal disease in adolescents with Down syndrome (DS) is 30% to 40%, and individuals in the next 30-40 years the percentage is about 100%. Authors suggest that periodontal disease in DS is consistent with the pattern of aggressive periodontitis, and is correlated with changes in the immune system of the same. In view of these changes, many researchers seek methods to supporting basic periodontal therapy such as combination with antibiotics, but their indiscriminate use can lead to resistant bacteria strains. Photodynamic therapy, a combination of photosensitizing agent or dye to a light source, and has been extensively studied with promising results. The present report deals with photodynamic therapy in the treatment of periodontal disease in an individual with Down syndrome.

A periodontite é uma doença inflamatória induzida por bactérias do biofilme da placa bacteriana localizadas na superfície subgengival. A inflamação conduz a formação de bolsa no tecido gengival, perda de inserção, destruição óssea e ultimamente uma possível perda dentária. A prevalência de doença periodontal em adolescentes com síndrome de Down (SD) é de 30% a 40%, sendo que em indivíduos próximos aos 30 ao 40 anos a porcentagem é de cerca de 100%. Autores sugerem que a doença periodontal na SD é compatível com o padrão de periodontite agressiva, e tem relação com as alterações no sistema imunes dos mesmos. Em vista destas alterações, muitos pesquisadores buscam métodos coadjuvantes à terapia periodontal básica, como associação com antibióticos, porém seu uso indiscriminado pode levar à resistência das cepas bacterianas. A terapia fotodinâmica, associação agente fotossensibilizador a uma fonte de luz, vem sendo muito estudado e com resultados promissores. O presente relato aborda a terapia fotodinâmica no tratamento da doença periodontal em um individuo com síndrome de Down.

Influência do gel de sinvastatina tópico no destorque de implantes instalados em tíbias de coelhos / Influence of simvastatin gel on implant torque removal values: a rabbit tibia model

O objetivo deste estudo foi avaliar a influência do gel de sinvastatina tópico no destorque de implantes instalados em tíbias de coelhos. Foram realizadas 32 cirurgias em 16 coelhos New Zealand para instalação de dois implantes em uma de suas tíbias. Um dos alvéolos foi previamente preenchido com o gel de estatina 30 mg/ml. O torque inicial foi de 20 Ncm e o destorque foi avaliado aos 28 e 56 dias com torquímetro Tohnichi. Os alvéolos cirúrgicos foram divididos em grupo IG -28 (teste - 28 dias): oito implantes + gel - 28 dias (IG-28); grupo IG-56 (teste - 56 dias): oito implantes + estatina - 56 dias (IG-56); grupo I-28 (controle - 28 dias): oito implantes - 28 dias (I-28); grupo I-56 (controle 56 dias): oito implantes - 56 dias (I-56). Valores do grupo IG-56 foram maiores que os grupos IG-28, I-28 e I-56 (p < 0,05). O gel de estatina aumentou a força de destorque no grupo IG-56 (teste 56 dias).

The aim of this study was to evaluate the influence of topical simvastatin application on implant removal torque values using a rabbit tibia model. Thirty-two surgeries were performed on 16 New Zealand rabbits for installation of two implants. One of the alveolus was first filled with the 30 mg/ml of simvastatin gel. The initial torque was 20 Ncm and removal torque was evaluated at 28 and 56 days with a Tohnichi torque wrench. The alveoli were divided into surgical Group IG-28: eight implants + simvastatin - 28 days, group IG-56 (test 56 days): eight implants + simvastatin - 56 days, group I-28 (control - 28 days): eight implants - 28 days, group I-56 (control 56 days): eight implants - 56 days. Mean values of group IG-56 were higher than groups IG-28, I-28 and I-56 (p < 0.05). Groups IG-28, I-28 and I-56 were similar (p > 0.05). The simvastatin gel increased torque removal values in group IG-56 (test - 56 days).

Ellis-van Creveld syndrome: oral manifestations and treatment / Síndrome Ellis-van Creveld: manifestações bucais e tratamento

The Ellis-van Creveld syndrome (EVC) or chondroectodermal dysplasia is a rare autosomal recessive disease, with incidence of 1:244,000 for the general population. The exact prevalence is unknown, but believed to be a genetic chromosomal disorder and a higher incidence in women. EVC consist of a tetrad of principal features: chondroectodermal dysplasia, polydactyly, congenital heart defects, and hypoplastic nails and teeth. In this syndrome many other organs can be compromised and other oral manifestations may be present. We report a case of a patient, 17 years old, female, presenting the typical features of EVC and the medical report confirming the condition. Attended at the Center for the Studies and Care of Special Patients of University Paulista - São Paulo, Brazil, seeking dental treatment, reported being dissatisfied with the aesthetic. We analyze the events and the patient's oral condition and its treatment recommended. This study was previously submitted and approved by the University Paulista Ethic Committee with the protocol nº 642/09.

A síndrome de Ellis-van Creveld (EVC) ou displasia condroectodérmica é uma rara doença autossômica recessiva, cuja incidência na população em geral é de 1:224.000. A prevalência exata é desconhecida, acredita-se ser uma desordem genética cromossômica e de maior incidência em mulheres. A EVC é dada pela presença tétrade característica: displasia condroectodérmica, polidactilia, defeitos cardíacos congênitos e unhas e dentes hipoplásicos. Além da tétrade, muitos outros órgãos podem ser comprometidos e outras manifestações bucais podem se fazer presentes. Relata-se um caso clínico de uma paciente, 17 anos, gênero feminino, apresentando as típicas características da EVC e confirmando com laudo médico a patologia. Compareceu ao Centro de Estudos e Atendimento a Pacientes Especiais da UNIP em busca de tratamento odontológico e relatou estar insatisfeita com a estética. Foram analisadas as manifestações e condições bucais da paciente e seu tratamento preconizado.