UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3799
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Braz Dent Sci 2023 July/Sept; 26 (3): e3799
Impact of the COVID-19 pandemic on the gingival health of children
and adolescents with cerebral palsy
Impacto da pandemia do COVID-19 na saúde gengival de crianças e adolescentes com paralisia cerebral
Vanessa Lira SIQUEIRA1 , Valéria Bordallo PACHECO1 , Gabriela Mancia de GUTIERREZ2 , Michele Baf DINIZ1 ,
Maria Teresa Botti Rodrigues dos SANTOS1
1 - Universidade Cruzeiro do Sul, Departamento de Odontologia, Programa de Pós-graduação em Odontologia. São Paulo, SP, Brazil.
2 - Faculdade São Leopoldo Mandic, Departamento de Odontologia, Programa de Pós-graduação em Odontopediatria. Campinas, SP, Brazil.
How to cite: Siqueira VL, Pacheco VB, Gutierrez GM, Diniz MB, Santos MTBR. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy. Braz Dent Sci. ANO;26(3):e3799. https://doi.org/10.4322/bds.2023.e3799
ABSTRACT
Objective: to evaluate the impact of the COVID-19 pandemic on children and adolescents with cerebral palsy, comparing the gingival
condition and the type of dental treatment before and after the interruption of dental care. Material and Methods: the retrospective
longitudinal study consisted of 273 participants undergoing Dental Clinic of the AACD (Disabled Child Assistance Association),
divided into three groups according to age: Group 1 (G1: 0 to 5 years and 11 months; n=137), Group 2 (G2: 6 to 11 years
and 11 months; n=85) and Group 3 (G3: 12 to 17 years and 11 months; n=51). Sociodemographic, data, clinical pattern
of cerebral palsy and use of medication were collected, evaluating the gingival condition by the gingival index and the type
of dental treatment before the pandemic and during, nine months after the interruption of dental care. Chi-square, Fisher
Exact and Kruskal-Wallis (α=5%) tests were used. Results: the groups were homogeneous in terms of sex (p=0.4581),
race (p=0.1725), clinical pattern (p=0.3482) and use of antiepileptic drugs (p=0.3509). Regarding the gingival condition,
in the period during the pandemic, there was a reduction in the number of participants with Gingival Index scores
0 and 1 and an increase in participants with scores 2 and 3 (p<0.05). As for the procedures performed, the three groups
showed a reduction in preventive procedures (p<0.05) and an increase in surgical, periodontal and restorative procedures
(p<0.05). Conclusion: it is concluded that the interruption of dental care for nine months during the COVID-19 pandemic
in children and adolescents with cerebral palsy had a negative impact on oral health.
KEYWORDS
COVID-19; Caregivers; Gingivitis; Oral health; Cerebral palsy.
RESUMO
Objetivo: avaliar o impacto da pandemia da COVID-19 em crianças e adolescentes com Paralisia Cerebral, comparando
a condição gengival e o tipo de tratamento odontológico antes e após a interrupção dos atendimentos odontológicos.
Material e Métodos: o estudo longitudinal retrospectivo foi composto por 273 participantes atendidos na Clínica odontológica
da AACD (Associação de Assistência à Criança Deciente), reunidos em três grupos segundo a faixa etária: Grupo 1
(G1: 0 a 5 anos e 11 meses; n=137), Grupo 2 (G2: 6 a 11 anos e 11 meses; n=85) e Grupo 3 (G3: 12 a 17 anos e 11 meses; n=51).
Foram coletados dados sociodemográcos, padrão clínico da Paralisia Cerebral e o uso de medicação, avaliando a condição
gengival pelo índice gengival e o tipo de tratamento odontológico antes e durante a pandemia, nove meses após a interrupção dos
atendimentos. Foram empregados os testes Qui-quadrado, Exato de Fisher e Kruskal-Wallis (α=5%). Resultados: os grupos eram
homogêneos quanto ao sexo (p=0,4581), raça (p=0,1725), padrão clínico (p=0,3482) e uso de drogas antiepiléticas (p=0,3509).
Com relação à condição gengival, no período Durante Pandemia, observou-se redução no número de participantes com escores
Índice Gengival 0 e 1 e aumento de participantes com escores 2 e 3 (p<0,05). Quanto aos procedimentos realizados, os três
grupos apresentaram redução de procedimentos preventivos (p<0,05) e aumento dos procedimentos cirúrgicos, periodontal e
restaurador (p<0,05). Conclusão: conclui-se que a interrupção do acompanhamento odontológico por nove meses na pandemia
da COVID-19 em crianças e adolescentes com PC acarretou impacto negativo na saúde bucal.
PALAVRAS-CHAVE
COVID-19; Cuidadores; Gengivite; Saúde bucal, Paralisia cerebral.
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Siqueira VL et al.
Impact of the COVID-19 pandemic on the gingival health of children and adolescents with cerebral palsy
Siqueira VL et al. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy
INTRODUCTION
COVID-19 was first detected in China in
December 2019 and is characterized by a respiratory
disease caused by the SARS-CoV-2 virus capable
of causing mild to severe infections in humans.
This virus spread to other countries, starting
the most recent global epidemic [1]. The World
Health Organization (WHO) declared it a public
health emergency of international concern [2].
In July 2020, more than 14,765,256 conrmed
cases were registered in only 24 hours, with a
mortality rate of approximately 3.7% in more than
200 countries [3]. Restrictive measures imposed by
states and municipalities in the face of the pandemic
were recommended, guiding social distancing
as a dissemination strategy to reduce cases and
control of the disease [4], resulting in measures
of temporary suspension of face-to-face preventive
dental care [5], due to the high risk of transmission
in a dental environment, by respiratory droplets in
suspension or by the production of aerosols [6].
It is known that children with cerebral palsy
(CP) are at greater risk for COVID-19 due to biological
and medical factors [7]. CP encompasses a group
of developmental disorders related to movement
and posture that cause limitations in the execution
of daily life tasks. In addition to disturbances in
motor function, the most common comorbidities
are cognitive and behavioral changes, epilepsy,
changes in oral motor functions and speech [8].
It is considered the most common cause of physical
disability in childhood [9], with a prevalence of
1.77 in developed countries. per thousand live
births [10] and in developing countries of 7 per
thousand [11], with greater expression among
white male children [12,13]. The spastic movement
disorder is the most common (increased muscle tone),
and is present in 80% of the cases. Clinical types
include quadriplegia (involvement of all four limbs,
swallowing difficulties and epilepsy), diplegia
(greater involvement in the lower limbs and
epilepsy) and hemiplegia (complete involvement of
one side of the body, and epilepsy [14]. Movement
disorder dyskinetic corresponds to about 10% of
cases, characterized by the presence of involuntary
movement, causing great difculty in performing
automatic movements and maintaining posture [15].
Among the factors that interfere with oral
hygiene, the presence of primitive oral reexes such
as biting and vomiting [16], the continuous use of
antiepileptic medications that lead to a reduction
in salivary ow [17], in the buffering capacity and
higher values of salivary osmolarity, favoring the
accumulation of pathogenic microorganisms and
gingival inammation, leading to the development
of caries and periodontal diseases. Thus, these
individuals are considered vulnerable to these
diseases [18,19].
As children and adolescents with CP have
difficulties in performing oral hygiene and have
suboptimal hygiene habits, this group is considered at
risk for oral diseases, requiring the participation of the
caregiver as an active member for the maintenance
of oral health. However, either due to the lack of
understanding/cooperation of the caregiver, or the
overload of the rehabilitation program, oral diseases
are often observed in these individuals [20]. The
knowledge acquired and the guidance received at the
institution of reference in rehabilitation related to oral
health are fundamental for adaptation, overcoming
and coping with difculties [21].
Since maintaining oral health requires periodic
preventive visits for children and adolescents with
CP and the oral literature is scarce regarding the oral
health of the individuals during the pandemic. The
Study hypothesis is that the interruption of dental
care during the COVID-19 pandemic has a negative
impact on the oral health of participants, Thus the
objective of this study was to evaluate the impact of
the COVID-19 pandemic on children and adolescents
with CP, comparing the gingival condition and
the type of dental treatment before and after the
interruption of dental care for nine months.
MATERIAL AND METHODS
Ethics statement
According to the resolution 466/2012 of
Ministry of Health. Written informed consent
form was obtained from the guardian of each
participant after they were informed about
the study objectives. The Research Ethics in
Committee of AACD (Disabled Child Assistance
Association) approved this study at #4.944.343,
São Paulo, Brazil.
Study design
A retrospective longitudinal study was carried
out, with a convenience sample, consisting of
children and adolescents diagnosed with CP,
undergoing physical rehabilitation and dental
treatment at the at the Dental Clinic of the AACD
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Impact of the COVID-19 pandemic on the gingival health of children and adolescents with cerebral palsy
Siqueira VL et al. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy
(Disabled Child Assistance Association), São Paulo,
Brazil at the time of data collection.
Participants
A total of 273 children and adolescents with
a medical diagnosis of spastic or dyskinetic CP, of
both gender and aged between 0 and 17 years and
11 months, undergoing rehabilitation treatment,
were invited to participate in this study. Children and
adolescents with progressive or neurodegenerative
lesions, who had used antibiotics in the last month,
non-collaborative behavior, or whose guardians
refused to sign the Free and Informed Consent Term
were excluded from the research. Before applying
the exclusion, criteria there were 543 participants.
Data collection
Demographic and clinical data related to
gender, age, race (white, black and others), medical
diagnosis of CP according to the type of movement
disorder (spastic and dyskinetic), clinical pattern
(tetraparesis, diparesis and hemiparesis) and
use of antiepileptic medication. The criterion for
distributing participants in the three age groups was
carried out according to the presence of deciduous
dentition (0 to 5 years and 11 months), mixed
(6 to 11 years and 11 months) and permanent
(12 to 17 years and 11 months) [22].
In order to assess the impact of the COVID-19
pandemic on the oral health of children and
adolescents with CP, records of the gingival condition
were collected by the gingival index (GI) and the
type of dental treatment (preventive, restorative,
periodontal and surgical) in two different periods:
(BP) before the pandemic (the last dental appointment
between June 2019 and February 2020) and (DP)
during the pandemic (rst appointment nine months
after the interruption of dental treatment between
the September 2020 to May 2021).
The evaluation of the Gingival Index (GI) [23]
was performed by a single trained and calibrated
examiner, specialist in Special care with six years of
experience, kappa 0,97, using a millimeter plastic
periodontal probe (HuFriedy’s Colorvue PerioScreen
Kit probe, Chicago, USA), which smoothly covered
the gingival margin of all teeth. Measurements
were made at six sites per tooth (mésio-, mid-, and
disto-buccal; mésio-, mid-, and disto-lingual) for
all teeth. Partially erupted teeth and residual roots
were excluded without replacement.
The GI was calculated by the percentage of the
sum of the individual values of each tooth, divided
by the number of faces examined, and categorized
according to the scores: score 0 = normal gingiva, no
bleeding on probing; score 1 = mild inammation -
slight change in color, slight edema but no bleeding
on probing;Categorized 0-1 (Good); score
2 = moderate inflammation - redness, edema
and glazing, bleeding on probing;Categorized
(Regular); score 3 = severe inammation - marked
redness and edema, ulceration with tendency to
spontaneous bleeding:Categorized (Poor). The
Gingival Index was employed, since this indicator
has been used by our research group [24].
Statistical analysis
Descriptive statistical analysis was performed
to characterize the sample, followed by the
application of non-parametric tests, since the data
did not present normal distribution. Chi-square
and Fisher’s Exact tests were used to compare
categorical and Kruskal-Wallis variables, with a
signicance level set at 5% (p<0.05) using the
statistical software IBM SPSS Statistics (SPSS for
Windows, Version 20.0, Armonk, USA).
RESULTS
Data were collected from 273 children and
adolescents with CP, divided into three groups
according to age: Group 1 (G1: 0 to 5 years and
11 months; n=137), Group 2 (G2: 6 to 11 years
and 11 months; n=85) and Group 3 (G3: 12 to
17 years and 11 months; n=51).
The groups were homogeneous in terms of
gender (p=0.4581), race (p=0.1725), clinical
pattern of CP (p=0.3482) and use of antiepileptic
medication (p=0.3509) (Table I).
The comparison of the results of the cross
tabulation related to the gingival health of
children and adolescents with CP in the two
moments BP (June 2019 to February 2020) and DP
(September 2020 to May 2021) showed that the
three groups differed signicantly, with reduction
in the number of participants with IG scores 0 to 1
(good) (p<0.0001) and an increase in participants
with IG scores 2 (regular) (p=0.0016) and 3 (poor)
(p=0.0002) (Table II).
The comparison of the results of the
cross-tabulation related to the type of dental
treatment performed in children and adolescents
with CP in the two moments BP (June 2019 to
February 2020) and DP (September 2020 to May
2021) showed that the three groups differed
significantly, with a reduction in preventive
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Impact of the COVID-19 pandemic on the gingival health of children and adolescents with cerebral palsy
Siqueira VL et al. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy
Table I - Sociodemographic and clinical characteristics of children and adolescents with CP according to the age groups
Sociodemographic and clinical characteristics Group 1 (n=137) Group 2 (n=85) Group 3 (n=51) p-value
Gender (n, %) (n, %) (n, %)
Female 65 (47.4) 38 (44.7) 19 (37.3)
p=0.4581ᵻ
Male 72 (52.6) 47 (55.3) 32 (62.7)
p-value p=0.6082ᵻp=0.3855ᵻp=0.0929ᵻ
Race (n, %) (n, %) (n, %)
White 100 (73.0) 60 (70.6) 45 (88.2)
p=0.1725ᵻ ᵻ
Black 3 (2.2) 3 (3.5) 1 (2.0)
Others 34 (24.8) 22 (25.9) 5 (9.8)
p-value p<0.0001ᵻ ᵻ p<0.0001ᵻ ᵻ p<0.0001ᵻ ᵻ
Clinical Pattern (n, %) (n, %) (n, %)
Tetraplegia 36 (26.3) 24 (28.2) 17 (33.3)
p=0.3482ᵻ ᵻ
Diplegica 64 (46.7) 43 (50.6) 17 (33.3)
Hemiplegia 26 (19.0) 16 (18.8) 13 (25.5)
Disknetcs 11 (8.0) 2 (2.4) 4 (7.8)
p-value p<0.0001ᵻp<0.0001ᵻ ᵻ p=0.0315ᵻ ᵻ
Antiepileptic drugs (n, %) (n, %) (n, %)
No use 94 (68.6) 57 (68.7) 34 (68.0)
p=0.3509ᵻ ᵻ
Calcium channel blocker 11 (8.0) 5 (6.0) 1 (2.0)
Sodium channel blocker 12 (8.8) 8 (9.6) 7 (14.0)
GABA inhibition 11 (8.0) 10 (12.0) 2 (4.0)
GABA inhibition AEDs 9 (6.6) 3 (3.6) 6 (12.0)
p-value p<0.0001ᵻp<0.0001ᵻ ᵻ p<0.0001ᵻ ᵻ
ᵻChi-square test. ᵻ ᵻFisher’s exact test.
Table II - Cross tabulation of the gingival condition of children and adolescents with CP before and after the return of dental care during the
COVID-19 pandemic according to the age groups
Group 1 Before Total (n, %)
Poor Regular Good
After
Poor 13 7 9 29 (21.2)
Regular 7 24 19 50 (36.5)
Good 2 6 50 58 (42.3)
Total (n, %) 22 (16.1) 37 (27.0) 78 (56.9) 137 (100.0)
Fisher’s exact test P<0.0001
Group 2 Before Total (n, %)
Poor Regular Good
After
Poor 5 4 2 11 (12.9)
Regular 6 15 24 45 (52.9)
Good 1 5 23 29 (34.1)
Total (n, %) 12 (14.1) 24 (28.2) 49 (57.6) 85 (100.0)
Fisher’s exact test P=0.0016
Group 3 Before Total (n, %)
Poor Regular Good
After
Poor 5 5 2 12 (23.5)
Regular 2 11 7 20 (39.2)
Good 0 3 16 19 (37.3)
Total (n, %) 7 (13.7) 19 (37.3) 25 (49.0) 51 (100.0)
Fisher’s exact test P=0.0002.
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Impact of the COVID-19 pandemic on the gingival health of children and adolescents with cerebral palsy
Siqueira VL et al. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy
procedures and an increase in surgical, periodontal
and restorative procedures [(G1: p<0.0001; G2:
p<0.0063; G3: p<0.0001)] (Table III).
DISCUSSION
This study conrmed the hypothesis that the
interruption of dental care during the COVID-19
pandemic had a negative impact on the gingival
health of children and adolescents with CP. Thus,
it was observed that children and adolescents with
CP evaluated in this research who were undergoing
physical rehabilitation and dental treatment at a
Reference Center need systematic preventive visits.
The mean age was 7.1 years old. It is known
that the sooner rehabilitation therapies are started,
the greater the motor progress will be. Early
intervention is guided by the critical moment of
development for the moldability of developing
systems [25], which justifies the action of the
institutional program.
The interruption of dental care during the
COVID-19 pandemic showed a worsening of the
gingival health of the participants in this study,
corroborating the observed results where children
with Cerebral Palsy have an increased risk of
dental caries and a lower gingival status [26].
The presence of primitive oral pathological
reexes makes individuals with CP more susceptible to
poor oral hygiene. The accumulation of biolm is the
main risk factor for the development of oral diseases,
such as dental caries and periodontal diseases [18,27].
These results corroborate the need for periodic and
systematic follow-up visits for this population.
With regard to dental treatments, the three
groups showed an increase in the need for
restorative, periodontal and surgical treatment,
with a consequent decrease in preventive
consultations. This fact can possibly be explained
by the increase in stress and anxiety levels in
response to the COVID-19 pandemic, impacting
on health behaviors, including changing eating
habits (with frequent intake of cariogenic foods)
Table III - Cross tabulation of the type of dental treatment of children and adolescents with CP before and after the return of dental care
during the COVID-19 pandemic according to the age groups
Group 1 Before Total (n, %)
Preventive Restorative Periodontal Surgery
After
Preventive 81 5 2 1 89 (65.0)
Restorative 17 9 1 2 29 (21.2)
Periodontal 5 0 3 2 10 (7.3)
Surgery 6 1 0 2 9 (6.6)
Total (n, %) 109 (79.6) 15 (10.9) 6 (4.4) 7 (5.1) 137 (100.0)
Fisher’s exact test p<0.0001
Group 2 Before Total (n, %)
Preventive Restorative Periodontal Surgery
After
Preventive 29 2 2 3 36 (42.4)
Restorative 9 5 0 1 15 (17.6)
Periodontal 7 0 3 2 12 (14.1)
Surgery 16 0 2 4 22 (25.9)
Total (n, %) 61 (71.8) 7 (8.2) 7 (8.2) 10 (11.8) 85 (100.0)
Fisher’s exact test p=0.0063
Group 3 Before Total (n, %)
Preventive Restorative Periodontal Surgery
After
Preventive 16 0 1 3 20 (39.2)
Restorative 2 4 0 0 6 (11.8)
Periodontal 9 1 10 1 21 (41.2)
Surgery 3 0 0 1 4 (7.8)
Total (n, %) 30 (58.8) 5 (9.8) 11 (21.6) 5 (9.8) 51 (100.0)
Fisher’s exact test p<0.0001.
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Siqueira VL et al. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy
and poor oral hygiene with reduced access to
dental services [28]. It should be noted that
children and adolescents with CP need help with
their daily oral hygiene, which may explain the
results found in the present study during the
pandemic, since some caregivers may have been
hesitant to help them for fear of infection, causing
further deterioration of oral health [29].
Among the most prevalent diseases worldwide
are oral diseases. They bring a lot of expense to
public coffers. The results of this study, coming
from an association can be extended to the public
or private service. These three groups probably
stopped returning with preventive procedures, for
more invasive procedures, generating more costs
for the institution, since, as in the public service,
prevention and health is much cheaper than
treating a disease [30].
In addition, the fear of parents, guardians
and caregivers in seeking dental care for their
children, as shown by recent studies [31].
The success of the treatment depends on the
adherence and interaction of the family, the
patient and the professionals [32]. It is essential
to start consultations early check-ups periodically,
according to the risk of the disease. These
measures facilitate the care of patients with
special needs who will be familiar with the
environment, with the professional and with the
treatment itself [33].
The inclusion model is guided by equity, in
order to allow access, opportunities, experiences
and rights to all children and adolescents [34],
meeting the guidelines of a reference institution
in São Paulo, Brazil that provides dental care for
children and adolescents with CP.
As for the movement disorder, the spastic
type was the most prevalent and had the highest
number of participants (n=64), with a clinical
pattern of diparesis. The interpretation of these
results suggests that a greater number of children
and adolescents with CP have been evolving
satisfactorily in the rehabilitation process,
compared to previous data from our research
group, which indicated the quadriplegic clinical
picture as the most common one [17].
With regard to gender, we once again
found a higher prevalence of males, in line with
previous ndings [17]. Possible explanations for
this sexual dimorphism would be due to greater
cortical folding in females [35].
As for race, the participants in this study
declared themselves to belong to the white
(75.1%), black (2.6%) and other (22.3%)
groups. In the last Census carried out in Brazil,
dated in 2010, the State System of Data Analysis
Foundation [36] has records that 63.9% of the
inhabitants of São Paulo declared themselves
white, 29.1% brown, 5.5% black, 1 .4% yellow
and 0.1% indigenous. Only 5.1% of the Brazilian
indigenous population lives in São Paulo.
Comparison of data from the white group in our
study resulted in an 11.2% increase compared to
SEADE data, as it is a recent data collection [36].
Regarding the use of antiepileptic
medication, it was observed that 68.8% of the
participants did not use drugs and 15.1% used the
inhibitory neurotransmitter gamma-aminobutyric
acid (GABA) and in associations (GABA and
antiepileptic drugs). The possible explanation
for the high number of participants not using
antiepileptic medication may be related to the
diparetic clinical pattern (48.4%) in contrast to
another study in which the largest number of CP
was composed of tetraparetic patients [17].
The study has some limitations that should be
pointed out. As these are children and adolescents
with CP, with associated comorbidities in most
cases, many of these did not return to dental care
after the resumption of consultations during the
COVID-19 pandemic, for fear of exposure and
contamination by the virus. In this sense, the
use of teledentistry could favor the monitoring
of these patients’ oral health. Another limitation
involves the non-collection of data regarding
eating habits and oral hygiene during the period
of social isolation [37].
We suggest further studies in children
and adolescents with CP and also with other
physical disabilities such as myelomeningocele,
osteogenesis imperfecta and congenital
malformation as a way to evaluate and promote
oral health in these populations, allowing a better
understanding of the factors that impacted oral
health in the pandemic of COVID-19.
This study demonstrates the important
role of dentists this population, as there was a
decrease in the number of individuals in the three
groups with no gingival inflammation after a
break in dental care. Consultations train skills and
motivate both caregivers and patients to perform
proper oral hygiene with the aim of promoting,
preventing and maintaining oral health.
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Impact of the COVID-19 pandemic on the gingival health of children and adolescents with cerebral palsy
Siqueira VL et al. Impact of the COVID-19 pandemic on the gingival health of
children and adolescents with cerebral palsy
CONCLUSION
It is concluded that the interruption of dental
follow-up for nine months during the COVID-19
pandemic in children and adolescents with
CP had a negative impact on gingival health.
It was observed in the three study groups, in
the three levels of gingival index, a reduction
in preventive procedures and an increase in
surgical, periodontal and restorative procedures,
when compared before and after the interruption
of dental care, thus, periodic and systematic
dental visits are necessary for children and
adolescents with CP, aiming at prevention and
health education activities, reducing the need for
invasive treatments.
Acknowledgements
We thank to the participants, parents and
teachers who helped me so much in this research.
Author’s Contributions
VLS, MBD, MTBRS: conceptualization, data
curation and writing - original draft preparation
GMG: methodology and formal analysis.
Conict of Interest
The authors have no proprietary, nancial,
or other personal interest of any nature or kind
in any product, service, and/or company that is
presented in this article.
Funding
Ministry of Education of Brazil, Brasília – DF,
Brazil, zip code 70.040-020 (CAPES – process
# 88887.699822/2022-00 for the nancial support.
Regulatory Statement
This research was approved by the Research
Ethics Committee of the AACD (Disabled Child
Assistance Association), São Paulo, Brazil (IRB#
4.944.343).
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Vanessa Lira Siqueira
(Corresponding address)
Universidade Cruzeiro do Sul, Departamento de Odontologia, Programa de
Pós-graduação em Odontologia, São Paulo, SP, Brazil.
Email: vanricsiqueira@gmail.com Date submitted: 2023 Feb 06
Accept submission: 2023 Aug 29
