Abstract
PURPOSE:
To assess periradicular lesions clinically and by computed tomography (CT) after endodontic surgery using either Portland cement or mineral trioxide aggregate (MTA) as a root-end filling material.
METHODS:
Three patients diagnosed with periradicular lesions by cone-beam CT underwent endodontic surgery with root-end filling. Patient A was treated with MTA as the root-end filling material, patient B was treated with Portland cement and patient C had two teeth treated, one with MTA and the other with Portland cement. Six months after surgery, the patients were assessed clinically and by CT scan and the obtained results were compared.
RESULTS:
Periradicular tissue regeneration was observed in all cases, with no significant differences in bone formation when comparing the use of MTA and Portland cement as root-end filling materials.
CONCLUSION:
Both mineral trioxide aggregate and Portland cement were successful in the treatment of periradicular lesions.
Apicoectomy; Oral Surgery; Biocompatible Materials; Dental Cements; Translational Medical Research
Introduction
Endodontic surgery is a therapeutic resource indicated when conventional endodontic
treatments fail. The development of biocompatible cements made this surgery a viable
alternative for the preservation of the tooth as a functional unit11. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral
trioxide aggregate when used as a root end filling material. J Endod.
1993;19(12):591-5. doi: http://dx.doi.org/10.1016/S0099-2399(06)80271-2.
https://doi.org/10.1016/S0099-2399(06)80...
,
22. Wada M, Takase T, Nakanuma K, Arisue K, Nagahama F, Yamazaki M.
Clinical study of refractory apical periodontitis treated by apicectomy. Part 1. Root
canal morphology of resected apex. Int Endod J. 1998;31(1):53-6. PMID: 8151252. . Root-end filling materials are required to
provide hermetic sealing and to be biocompatible and a precursor for carbonate-apatite
formation, which promotes biomineralization, resulting in periodontal ligament at the
bone-cement-dentin interface33. Reyes-Carmona JF, Felippe MS, Felippe WT. Biomineralization ability
and interaction of mineral trioxide aggregate and white Portland cement with dentin
in a phosphate-containing fluid. J Endod. 2009;35(5):731-6. doi:
10.1016/j.joen.2009.02.011. PMID: 19410094.
https://doi.org/10.1016/j.joen.2009.02.0...
.
Mineral trioxide aggregate (MTA), which was developed by Mahmoud Torabinejad, is
currently the cement of choice, meeting all requirements for use as a root-end filling
material44. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a
comprehensive literature review--Part III: Clinical applications, drawbacks, and
mechanism of action. J Endod. 2010;36(3):400-13. doi: 10.1016/j.joen.2009.09.009.
PMID: 20171353.
https://doi.org/10.1016/j.joen.2009.09.0...
. However, its high cost prevents its
use in the public health system.
Portland cement is the most common type cement used in civil engineering applications.
The major components of Portland cement are comparable to those of MTA, except for the
presence of the radiopaque agent bismuth oxide in MTA5,6. Other similarities
between the two materials include antimicrobial activity and biocompatibility7-117. Dreger LA, Felippe WT, Reyes-Carmona JF, Felippe GS, Bortoluzzi A,
Felippe MC. Mineral trioxide aggregate and Portland cement promote biomineralization
in vivo. J Endod. 2012;38(3):324-9. doi:10.1016/j.joen.2011.11.006. PMID: 22341069.
https://doi.org/10.1016/j.joen.2011.11.0...
.
The prospect of using Portland cement in the public health system means that dental
procedures such as endodontic surgeries can be performed at a lower cost1111. Silva Neto JD, Schnaider TB, Gragnani A, Paiva AP, Novo NF, Ferreira
LM. Portland cement with additives in the repair of furcation perforations in dogs.
Acta Cir Bras. 2012;27(11):809-14. doi.org/10.1590/S0102-86502012001100011 PMID:
23117614. .
https://doi.org/10.1590/S0102-8650201200...
. The present trend in the scientific community is
to recognize translational science (a branch of sciences that provides an integrated
approach to basic, social and political sciences) as an important tool to optimize the
distribution of resources from the public health care system to patients1212. Feldman AM. Does academic culture support translational research?
Clin Transl Sci. 2008;1(2):87-8. doi: 10.1111/j.1752-8062.2008.00046.x. PMID:
20443823.
https://doi.org/10.1111/j.1752-8062.2008...
. Translational science is a process of production
originated from evidence-based research that aims to provide sustainable solutions to
community health problems1313. Lean ME, Mann JI, Hoek JA, Elliot RM, Schofield G. Translational
research. BMJ. 2008;337:a863. doi: 10.1136/bmj.a863. PMID: 18755767 .
https://doi.org/10.1136/bmj.a863...
. It can be seen as a
strategy for solving issues of great social impact, and if focused on saving a tooth, it
may provide viable means to minimize the frequent loss of teeth that occur, especially
in the public health system.
The clinical use of Portland cement would be an alternative to MTA in root-end filling procedures. Portland cement has a lower cost and is readily available, which are important factors in developing countries. Thus, this study was conducted to compare periradicular tissue regeneration following endodontic surgery using Portland cement and MTA as root-end filling materials.
Methods
This was a pilot prospective clinical study conducted at the University of Vale do Sapucai, Pouso Alegre-MG, Brazil. The study was approved by the Institutional Ethics Committee (protocol number 1702/11). Written informed consent was obtained from all patients prior to their inclusion in the study and anonymity was assured.
Three adult patients, two female and a male, who had single-rooted teeth with persistent periradicular lesions were selected to participate in this study. The lesions were diagnosed with cone-beam computed tomography (cone-beam CT; Model i-Cat 17-19, Imaging Sciences International LLC). The dimensions of the long axes of the lesions in the bucco-palatal and coronal-apical directions were measured using CT images. Patient A, 21 years-old, underwent endodontic surgery of the maxillary left second premolar (tooth A) using MTA as a control root-end filling material. Patient B, 40 years-old, underwent endodontic surgery of the maxillary right lateral incisor (tooth B) with Portland cement as root-end filling material. Patient C, 42 years-old, underwent endodontic surgery of two teeth, the mandibular right central incisor (tooth C1) and the mandibular right lateral incisor (tooth C2). MTA was used as root-end filling material for tooth C1 and Portland cement was used for tooth C2.
Before the surgical procedure, the patients rinsed their mouth with 5 ml of 0.12% chlorhexidine digluconate for one minute. The patients received 2% lidocaine with noradrenaline 1:100,000 as supraperiosteal infiltration, according to conventional techniques. A relaxing incision was made in the gingival sulcus with a scalpel blade (no. 15). Blunt dissection was carried out with a Molt elevator; the apical lesion was located using a no.5 dental explorer; and osteotomy was made using an Ostby chisel and a carbide bur no. 4. Next, curettage of the lesion was done with a periodontal curette (no. 13/14). A low-speed bur (no. 700) was used for apicoectomy. A step-back instrumentation technique performed with an ultrasonic tip (SD90, Dabi Atlante(r), Brazil) was used for root-end cavity preparation. The cavity was dried with absorbent paper points and root-end filling was carried out with either MTA (teeth A and C1) or Portland cement (teeth B and C2). The root-end filling material was packed and the root was planed to the apical end using appropriate instruments. Periapical radiographs were obtained with a periapical film. The bone cavity was cleaned with sterile saline solution and filled with calcium carbonate powder. The flap was repositioned and secured with 4-0 silk suture. All patients were prescribed 875-mg amoxicillin-clavulanate potassium tablet twice daily for seven days, 4-mg dexamethasone tablet twice daily for three days, and 750-mg paracetamol tablet every four hours in the first postoperative day. The suture was removed seven days after surgery.
The teeth and surrounding tissues were assessed clinically and by CT scan at the 6-month follow-up.
The dimensions of the long axes of the lesions in the bucco-palatal and coronal-apical directions were measured preoperatively and 6-month postoperatively using CT images and descriptively compared.
Results
Images of the teeth A, B, and C1 and C2 obtained preoperatively and at the 6-month follow-up using a cone-beam CT scanner are shown in Figures 1, 2, 3 and 4, respectively.
Preoperative (baseline) and 6-month postoperative measurements obtained from the CT images are summarized in Table 1. The measurements show that the size of the lesion decreased over time in all teeth, indicating the formation of cortical bone.
Discussion
When conventional endodontic treatments fail, apicoectomy is an alternative to save the
tooth. However, cements used for root-end filling must meet certain requirements for the
success of the treatment33. Reyes-Carmona JF, Felippe MS, Felippe WT. Biomineralization ability
and interaction of mineral trioxide aggregate and white Portland cement with dentin
in a phosphate-containing fluid. J Endod. 2009;35(5):731-6. doi:
10.1016/j.joen.2009.02.011. PMID: 19410094.
https://doi.org/10.1016/j.joen.2009.02.0...
. MTA is a material that
has revolutionized endodontic procedures regarding tooth preservation. MTA is the cement
of choice because it meets standards of performance for root-end filling. However, the
high cost of MTA restricts its use44. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a
comprehensive literature review--Part III: Clinical applications, drawbacks, and
mechanism of action. J Endod. 2010;36(3):400-13. doi: 10.1016/j.joen.2009.09.009.
PMID: 20171353.
https://doi.org/10.1016/j.joen.2009.09.0...
. MTA has the
same basic composition of type I Portland cement with the addition of bismuth oxide as a
radiopaque agent1414. Húngaro Duarte MA, de Oliveira El Kadre GD, Vivan RR, Guerreiro
Tanomaru JM, Tanomaru Filho M, de Moraes IG. Radiopacity of Portland cement
associated with different radiopacifying agents. J Endod. 2009;35(5):737-40. doi:
10.1016/j.joen.2009.02.006. PMID: 19410095.
https://doi.org/10.1016/j.joen.2009.02.0...
. Because of this, some studies
have suggested that Portland cement may be used in the clinical practice1515. Saidon J, He J, Zhu Q, Safavi K, Spångberg LS. Cell and tissue
reactions to mineral trioxide aggregate and Portland cement. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2003;95(4):483-9. doi:
http://dx.doi.org/10.1067/moe.2003.20. PMID: 12686935.
https://doi.org/10.1067/moe.2003.20...
.
Portland cement has hydraulic properties and is used in civil construction. The
biological properties of type I Portland cement and MTA are very similar; both materials
release calcium ions, leading to the formation of carbonate apatite, which is involved
in biomineralization1010. Silva Neto JD, Brito RH, Schnaider TB, Gragnani A, Engelman M,
Ferreira LM. Root perforations treatment using mineral trioxide aggregate and
Portland cements. Acta Cir Bras. 2010;25(6):479-84.
doi.org/10.1590/S0102-86502010000600004. PMID: 21120277 .
https://doi.org/10.1590/S0102-8650201000...
,
1111. Silva Neto JD, Schnaider TB, Gragnani A, Paiva AP, Novo NF, Ferreira
LM. Portland cement with additives in the repair of furcation perforations in dogs.
Acta Cir Bras. 2012;27(11):809-14. doi.org/10.1590/S0102-86502012001100011 PMID:
23117614. .
https://doi.org/10.1590/S0102-8650201200...
,
1616. Menezes R, Bramante CM, Letra A, Carvalho VG, Garcia RB. Histologic
evaluation of pulpotomies in dog using two types of mineral trioxide aggregate and
regular and white Portland cements as wound dressings. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2004;98(3):376-9. doi:
http://dx.doi.org/10.1016/j.tripleo.2004.03.008. PMID: 15356480.
https://doi.org/10.1016/j.tripleo.2004.0...
,
1717. Min KS, Kim HI, Park HJ, Pi SH, Hong CU, Kim EC. Human pulp cells
response to Portland cement in vitro. J Endod. 2007;33(2):163-6. doi:
http://dx.doi.org/10.1016/j.joen.2006.07.022. PMID: 17258637.
https://doi.org/10.1016/j.joen.2006.07.0...
. Histological findings have demonstrated the
biocompatibility of Portland cement, even when additives are used to increase the
resistance of the cement1010. Silva Neto JD, Brito RH, Schnaider TB, Gragnani A, Engelman M,
Ferreira LM. Root perforations treatment using mineral trioxide aggregate and
Portland cements. Acta Cir Bras. 2010;25(6):479-84.
doi.org/10.1590/S0102-86502010000600004. PMID: 21120277 .
https://doi.org/10.1590/S0102-8650201000...
,
1111. Silva Neto JD, Schnaider TB, Gragnani A, Paiva AP, Novo NF, Ferreira
LM. Portland cement with additives in the repair of furcation perforations in dogs.
Acta Cir Bras. 2012;27(11):809-14. doi.org/10.1590/S0102-86502012001100011 PMID:
23117614. .
https://doi.org/10.1590/S0102-8650201200...
. These studies have served as a starting point
for other clinical studies to determine the feasibility of using Portland cement as a
biomaterial.
The design of the clinical study was initiated by this pilot study. One of the main
reasons for conducting a pilot study is to determine the initial data for the primary
outcome in order to perform a calculation of sample size for the major study1717. Min KS, Kim HI, Park HJ, Pi SH, Hong CU, Kim EC. Human pulp cells
response to Portland cement in vitro. J Endod. 2007;33(2):163-6. doi:
http://dx.doi.org/10.1016/j.joen.2006.07.022. PMID: 17258637.
https://doi.org/10.1016/j.joen.2006.07.0...
. It also involves checking the instruments and
procedures of the research on a small part of the sample1717. Min KS, Kim HI, Park HJ, Pi SH, Hong CU, Kim EC. Human pulp cells
response to Portland cement in vitro. J Endod. 2007;33(2):163-6. doi:
http://dx.doi.org/10.1016/j.joen.2006.07.022. PMID: 17258637.
https://doi.org/10.1016/j.joen.2006.07.0...
,
1818. Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot
studies: recommendations for good practice. J Eval Clin Pract. 2004;10(2):307-32.
doi: 10.1111/j..2002.384.doc.x. PMID: 15189396.
https://doi.org/10.1111/j..2002.384.doc....
. This study consisted of a mini version of the
full study - three patients and four teeth were part of this study - to observe
instruments and procedures of the method to ensure bias-free results.
Several authors performed pilot studies is to calibrate instruments for designing
studies with larger samples19-2219. Tricio J, Woolford M, Thomas M, Lewis-Greene H, Georghiou L,
Andiappan M, Escudier M. Dental students' peer assessment: a prospective pilot study.
Eur J Dent Educ. 2014 Aug 28. doi: 10.1111/eje.12114 PMID: 25168409.
.
https://doi.org/10.1111/eje.12114...
. We conducted a
pilot clinical study comparing outcomes of endodontic surgeries using either MTA or
Portland cement as a root-end filling material. Our results showed that restoration of
periradicular tissues occurred when Portland cement was used.
MTA is considered the gold standard, but its cost and the presence of bismuth oxide in
its composition are factors that must be taken into consideration when using MTA as a
root-end filling material. Bismuth oxide is added to MTA for radiopacity, but in the
long term bismuth oxide can cause changes in the cement, resulting in increased porosity
and decreased resistance55. Coomaraswamy KS, Lumley PJ, Hofmann MP. Effect of bismuth oxide
radioopacifier content on the material properties of an endodontic Portland
cement-based (MTA-like) system. J Endod. 2007;33(3):295-8. doi:
http://dx.doi.org/10.1016/j.joen.2006.11.018. PMID: 17320718.
https://doi.org/10.1016/j.joen.2006.11.0...
,
2323. Bueno CE, Zeferino EG, Manhães LR Jr, Rocha DG, Cunha RS, De Martin
AS.Study of the bismuth oxide concentration required to provide Portland cement with
adequate radiopacity for endodontic use. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2009;107(1):65-9. doi: 10.1016/j.tripleo.2008.09.016. PMID:19101486.
https://doi.org/10.1016/j.tripleo.2008.0...
. On the other hand, the presence of Portland
cement can be detected in radiographs without the addition of radiopaque agents.
The discussion on the use of Portland cement as an alternative to MTA is important
because it can determine whether or not it is possible to save a tooth that otherwise
would be extracted. The high cost of MTA makes its use prohibitive in the public health
system2424. Porter ME. A strategy for health care reform-toward a value-based
system. N Engl J Med. 2009;361(2):109-12. doi: 10.1056/nejmp0904131. PMID: 19494209.
https://doi.org/10.1056/nejmp0904131...
. Researchers must make efforts to
combine discoveries of basic science and findings of clinical investigations, and
transform these results into changes in clinical practice1313. Lean ME, Mann JI, Hoek JA, Elliot RM, Schofield G. Translational
research. BMJ. 2008;337:a863. doi: 10.1136/bmj.a863. PMID: 18755767 .
https://doi.org/10.1136/bmj.a863...
. The present pilot study provides a basis for further clinical studies
with a larger sample size, using Portland cement as a biomaterial and aiming to
contribute to dental rehabilitation.
Conclusion
Both mineral trioxide aggregate and Portland cement were successful in the treatment of periradicular lesions.
References
-
1Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19(12):591-5. doi: http://dx.doi.org/10.1016/S0099-2399(06)80271-2.
» https://doi.org/10.1016/S0099-2399(06)80271-2 -
2Wada M, Takase T, Nakanuma K, Arisue K, Nagahama F, Yamazaki M. Clinical study of refractory apical periodontitis treated by apicectomy. Part 1. Root canal morphology of resected apex. Int Endod J. 1998;31(1):53-6. PMID: 8151252.
-
3Reyes-Carmona JF, Felippe MS, Felippe WT. Biomineralization ability and interaction of mineral trioxide aggregate and white Portland cement with dentin in a phosphate-containing fluid. J Endod. 2009;35(5):731-6. doi: 10.1016/j.joen.2009.02.011. PMID: 19410094.
» https://doi.org/10.1016/j.joen.2009.02.011 -
4Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-13. doi: 10.1016/j.joen.2009.09.009. PMID: 20171353.
» https://doi.org/10.1016/j.joen.2009.09.009 -
5Coomaraswamy KS, Lumley PJ, Hofmann MP. Effect of bismuth oxide radioopacifier content on the material properties of an endodontic Portland cement-based (MTA-like) system. J Endod. 2007;33(3):295-8. doi: http://dx.doi.org/10.1016/j.joen.2006.11.018. PMID: 17320718.
» https://doi.org/10.1016/j.joen.2006.11.018 -
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7Dreger LA, Felippe WT, Reyes-Carmona JF, Felippe GS, Bortoluzzi A, Felippe MC. Mineral trioxide aggregate and Portland cement promote biomineralization in vivo. J Endod. 2012;38(3):324-9. doi:10.1016/j.joen.2011.11.006. PMID: 22341069.
» https://doi.org/10.1016/j.joen.2011.11.006 -
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10Silva Neto JD, Brito RH, Schnaider TB, Gragnani A, Engelman M, Ferreira LM. Root perforations treatment using mineral trioxide aggregate and Portland cements. Acta Cir Bras. 2010;25(6):479-84. doi.org/10.1590/S0102-86502010000600004. PMID: 21120277 .
» https://doi.org/10.1590/S0102-86502010000600004 -
11Silva Neto JD, Schnaider TB, Gragnani A, Paiva AP, Novo NF, Ferreira LM. Portland cement with additives in the repair of furcation perforations in dogs. Acta Cir Bras. 2012;27(11):809-14. doi.org/10.1590/S0102-86502012001100011 PMID: 23117614. .
» https://doi.org/10.1590/S0102-86502012001100011 -
12Feldman AM. Does academic culture support translational research? Clin Transl Sci. 2008;1(2):87-8. doi: 10.1111/j.1752-8062.2008.00046.x. PMID: 20443823.
» https://doi.org/10.1111/j.1752-8062.2008.00046.x -
13Lean ME, Mann JI, Hoek JA, Elliot RM, Schofield G. Translational research. BMJ. 2008;337:a863. doi: 10.1136/bmj.a863. PMID: 18755767 .
» https://doi.org/10.1136/bmj.a863 -
14Húngaro Duarte MA, de Oliveira El Kadre GD, Vivan RR, Guerreiro Tanomaru JM, Tanomaru Filho M, de Moraes IG. Radiopacity of Portland cement associated with different radiopacifying agents. J Endod. 2009;35(5):737-40. doi: 10.1016/j.joen.2009.02.006. PMID: 19410095.
» https://doi.org/10.1016/j.joen.2009.02.006 -
15Saidon J, He J, Zhu Q, Safavi K, Spångberg LS. Cell and tissue reactions to mineral trioxide aggregate and Portland cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(4):483-9. doi: http://dx.doi.org/10.1067/moe.2003.20. PMID: 12686935.
» https://doi.org/10.1067/moe.2003.20 -
16Menezes R, Bramante CM, Letra A, Carvalho VG, Garcia RB. Histologic evaluation of pulpotomies in dog using two types of mineral trioxide aggregate and regular and white Portland cements as wound dressings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98(3):376-9. doi: http://dx.doi.org/10.1016/j.tripleo.2004.03.008. PMID: 15356480.
» https://doi.org/10.1016/j.tripleo.2004.03.008 -
17Min KS, Kim HI, Park HJ, Pi SH, Hong CU, Kim EC. Human pulp cells response to Portland cement in vitro. J Endod. 2007;33(2):163-6. doi: http://dx.doi.org/10.1016/j.joen.2006.07.022. PMID: 17258637.
» https://doi.org/10.1016/j.joen.2006.07.022 -
18Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot studies: recommendations for good practice. J Eval Clin Pract. 2004;10(2):307-32. doi: 10.1111/j..2002.384.doc.x. PMID: 15189396.
» https://doi.org/10.1111/j..2002.384.doc.x -
19Tricio J, Woolford M, Thomas M, Lewis-Greene H, Georghiou L, Andiappan M, Escudier M. Dental students' peer assessment: a prospective pilot study. Eur J Dent Educ. 2014 Aug 28. doi: 10.1111/eje.12114 PMID: 25168409. .
» https://doi.org/10.1111/eje.12114 -
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21Janner SF1, Jeger FB, Lussi A, Bornstein MM. Precision of endodontic working length measurements: a pilot investigation comparing cone-beam computed tomography scanning with standard measurement techniques. J Endod. 2011;37(8):1046-51. doi: 10.1016/j.joen.2011.05.005. PMID: 21763892.
» https://doi.org/10.1016/j.joen.2011.05.005 -
22Dakhilalian M, Rismanchian M, Fazel A, Basiri K, Azadeh H, Mahmoodi M, Fayazi S, Sadr-Eshkvari P. Conventional versus implant-retained overlay dentures: a pilot study of masseter and anterior temporalis electromyography. J Oral Implantol. 2014;40(4):418-24. doi: 10.1563/aaid-joi-d-11-00190. PMID: 25106005.
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23Bueno CE, Zeferino EG, Manhães LR Jr, Rocha DG, Cunha RS, De Martin AS.Study of the bismuth oxide concentration required to provide Portland cement with adequate radiopacity for endodontic use. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(1):65-9. doi: 10.1016/j.tripleo.2008.09.016. PMID:19101486.
» https://doi.org/10.1016/j.tripleo.2008.09.016 -
24Porter ME. A strategy for health care reform-toward a value-based system. N Engl J Med. 2009;361(2):109-12. doi: 10.1056/nejmp0904131. PMID: 19494209.
» https://doi.org/10.1056/nejmp0904131
-
Financial source: none
-
1Research performed at Department of Surgery, School of Medicine, University of Vale do Sapucai (UNIVAS), Pouso Alegre-MG, Brazil. Part of Master degree thesis, Professional Masters in Sciences Applied to Health, UNIVAS. Tutor: Taylor Brandão Schnaider.
Publication Dates
-
Publication in this collection
Feb 2015
History
-
Received
28 Oct 2014 -
Reviewed
26 Dec 2014 -
Accepted
20 Jan 2015