Vigilancia clínica-microbiológica de una Periodontitis Grado C etapa III en cinco años / Clinical-microbiological vigilance of a C Grade Periodontitis Stage III in five years

Resumen Introducción: Diversas técnicas se utilizan para tratar y mantener los dientes afectados con Periodontitis de estadio III grado C, sin embargo, hay poca información sobre cómo se modifican los parámetros clínicos periodontales y la composición microbiológica durante el tratamiento convencional y quirúrgico. Objetivo: Evaluar la respuesta clínica y microbiológica en una paciente con periodontitis estadio III grado C generalizada durante 5 años. Cuyo tratamiento consistió en terapia periodontal no quirúrgica y quirúrgica utilizando material regenerativo y sustituto óseo. Metodología: Se realizó raspado y alisado radicular progresivo, combinado con antibióticos y cirugía en sitios con defectos infraóseos. Se tomó registro de placa bacteriana subgingival (PB), hemorragia (H), profundidad de la bolsa (PS) y nivel de inserción clínica (NIC) en cada momento del tratamiento. Se tomaron muestras de la profundidad de las bolsas para identificar bacterias periodontales por biología molecular. Resultados: Se observó una mejoría de PB, H, PS y ganancia de NIC a lo largo de los 5 años. Con los injertos óseos la PS disminuyó 5 mm y de NIC se ganó 5 mm, con amelogeninas las diferencias fueron de 4,5 mm respectivamente. En colgajos de acceso, la PS disminuyó 3 mm y de NIC se ganó 2 mm. Se identificó T.denticola a los 36 meses, en todas las bolsas tratadas con colgajo de acceso y en el 50% de las bolsas con injertos óseos; y P. gingivalis a los 60 meses. Conclusiones: El tratamiento periodontal aplicado evitó la pérdida de los dientes afectados. El mejoramiento de los parámetros clínicos se asoció con una microbiota no agresiva.

Abstract Introduction: There are several techniques to treat and maintain teeth affected by stage III, grade C periodontitis, nonetheless, the scientific evidence available on how periodontal clinical parameters and microbiological composition may be modified during the conventional and surgical treatment is scarce. Objective: To evaluate the clinical and microbiological response of a patient with stage III grade C, generalized periodontitis, during 5 years, treated with non-surgical and surgical periodontal therapy using regenerative material and bone substitute. Methodology: The patient was treated with scaling and progressive root planning, combined with antibiotics and surgical therapy was performed in sites with infraosseous defects. At each time of treatment, subgingival bacterial plaque (PB), haemorrhage (H), probing depth (PD) and clinical attachment level (CAL) were recorded. To identify periodontal bacteria by molecular biology samples were taken with endodontic cones from the pocket depth. Results: A significant difference of PB, H, PD was observed. The PD decreased and CAL was gained throughout the treatment. PD decreased 5 mm with the application of bone substitute, and CAL gained 5 mm, with the use of amelogenins the difference of PD and CAL was 4.5 mm. In access flap the PD decreased 3 mm and the CAL improved 2 mm. T. denticola was identified at 36 months in all pockets treated with access flap and in 50% of the pockets with bone graft, and P. gingivalis at 60 months. Conclusions: The periodontal treatment applied prevented the loss of the affected teeth. Improvement of clinical parameters was associated with a non-aggressive microbiota.

Cirugía ósea resectiva / Resective osseous surgery

Una de las causas de la evolución de la periodontitis es la formación de defectos óseos y pérdida de inserción clínica. Una manera de eliminar el defecto intraóseo y su bolsa periodontal es eliminar las paredes de hueso que componen el defecto para colocar el complejo dentogingival en una posición más apical. La cirugía ósea es un procedimiento periodontal resectivo que involucra la modificación del tejido óseo del soporte dental, la cual es una modalidad del tratamiento periodontal quirúrgico que puede utilizarse para eliminar eficazmente los defectos óseos periodontales para estabilizar la inserción periodontal. El objetivo del presente estudio es realizar una revisión de la literatura sobre las consideraciones actuales, técnicas y principios de la cirugía ósea resectiva en el paciente periodontalmente comprometido (AU)

One of the causes of the evolution of periodontitis is the formation of bone defects and loss of clinical attachment, where one way to eliminate the intraosseous defect and its periodontal pocket is to eliminate the bone walls that make up the defect to place the dentogingival complex in a more apical position. Bone surgery is periodontal surgery that involves the modification of the supporting bone tissue of the teeth, which is a modality of surgical treatment that can be used to effectively eliminate periodontal defects and stabilize the periodontal insertion. The aim of the present study is to conduct a literature review about the considerations, techniques and principles of resective bone surgery in the periodontally compromised patient (AU)

Literature Review: Dental Aspects in Gaucher Disease / Revisión de la Literatura: Aspectos Dentales en la Enfermedad de Gaucher

SUMMARY: Knowledge about Gaucher disease, characteristics, clinical and radiographic alterations, demonstrate the importance of using anamnesis, laboratory tests and radiological images, among these dental analysis and images, making possible the early detection in the oral manifestations and the success in the control and treatment of the disease.

RESUMEN: El conocimiento sobre la enfermedad de Gaucher, características, alteraciones clínicas y radiográficas, demuestra la importancia de utilizar la anamnesis, los exámenes de laboratorio e imágenes radiológicas, entre ellas las odontológicas, posibilitando la detección precoz de las manifestaciones orales, y el éxito en el control y tratamiento de la enfermedad.

Laser Assisted Periodontal Therapy: A Case Series.

Periodontitis is a one of the commonly occurring disease. Various therapies have been used and suggested for its treatment which includes nonsurgical, antimicrobial, and surgical therapy. In the recent years, lasers have been used frequently for periodontal therapy. Lasers have been applied for debridement, reshaping as well as the reduction of bacterial load in the pocket. This case series represent the use of lasers for exposure of impacted teeth, second stage surgery for dental implant, and vestibuloplasty. The surgical procedure with a 810 nm diode laser has been described. The laser-assisted procedures provided excellent results without complications as well as high patient and clinician satisfaction.

Platelet-Rich Fibrin a Second Generation Autologous Platelet Concentrate for the Treatment of Inadequate Width of Attached Gingiva.

Along with the better understanding of the pathogenesis of periodontal diseases, the treatment modalities for various periodontal diseases have also gone a step ahead. One of the most important and currently unsolved problems in clinical periodontics is the predictable successful treatment of inadequate width of attached gingiva. Recently, importance has been given to the use of platelet-rich fibrin (PRF) for predictably treating periodontal diseases. PRF is an intimate assembly of glycan chains, glycoproteins, and cytokines. These are enmeshed in a slowly polymerized fibrin network which has the potential to accelerate soft and hard tissue healing. This article presents the clinical results of treatment of inadequate width of attached gingiva with PRF.

Detección de microorganismos anaerobios en pacientes con pericoronaritis y sensibilidad a los antimicrobianos / Anaerobic microorganisms detection in patients with pericoronaritis and antimicrobial susceptibility

El propósito de este estudio fue la identificación de microorganismos anaerobios más frecuentemente encontrados en pericoronaritis y realizar pruebas de sensibilidad a los antimicrobianos. Se estudiaron los sacos pericoronarios del tercer molar en 20 pacientes. De las muestras recogidas en los 20 pacientes que presentaron pericoronaritis, solo en 7 (35%) hubo crecimiento de microorganismos anaerobios estrictos mientras que en los 13 restantes (65%) no se detectaron estos. En cuanto a las 12 cepas aisladas del saco pericoronario de los 7 pacientes, el microorganismo más frecuentemente encontrado fue Bifidobacterium spp en 5 casos (42%), Bifidobacterium adolescentis en 2 casos (17%), Veillonella spp en dos casos también (17%), Prevotella melaninogenica en 1 caso (8%), 1 caso Prevotella loescheii (8%) y en 1 caso a Prevotella oralis (8%). De los resultados obtenidos las bacterias anaerobias estrictas detectadas a partir de muestras de sacos pericoronarios fueron: Bifidobacterium spp., B. adolescentis, Veillonella spp, P. loeschii, P. melaninogenica y P. oralis.

Periodontal response to subgingival restorations in dogs with periodontitis

The aim of this study was to evaluate the periodontal response to subgingival restorations in dogs with naturally occurring periodontitis. At the baseline, the experimental teeth from three dogs (2nd and 3rd upper premolars and 2nd, 3rd and 4th lower premolars) were randomly assigned to Resin-modified Glass Ionomer Cement (RMGIC) and Amalgam (AM) restorations or controls (CT) at the buccal sites with (SUPRA+) or without mechanical supragingival plaque control (SUPRA-) and maintained for 90 days. Clinical [Periodontal Probing Depth (PPD), Clinical Attachment Loss (CAL), and Gingival Margin Recession (GMR)], histological (connective tissue inflammatory and epithelium condition) and histometric evaluation (distance between the apical border of the cavity and the bone level and between the apical extension of the epithelium and the bone level) were performed by a calibrated blinded examiner. Better clinical (especially regarding CAL) and histological results (unaltered epithelium and less severe inflammatory connective tissue) were observed associated with RMGIC sites. Histometric evaluation showed less bone loss associated to RMGIC. Overall, SUPRA+ sites presented less inflammatory response. It could be concluded that in dogs with periodontitis, subgingival RMGIC restorations, especially in the presence of supragingival plaque control, elicited better periodontal response than AM restorations.

O objetivo do presente estudo foi avaliar a resposta do periodonto a restaurações subgengivais em cães com diagnóstico de periodontite. No início do estudo, os dentes experimentais de três cães (2o e 3o molares superiores e 2o, 3o e 4o premolares inferiores) foram randomicamente designados para restauração com cimento de ionômero de vidro modificado por resina (CIVMR), amálgama (AM) ou Controle (CT) nos sítios vestibulares submetidos (SUPRA+) ou não (SUPRA-) a controle mecânico de placa supragengival e mantidos por 90 dias. Avaliações clínicas [Profundidade de Sondagem (PS), Nível de Inserção Clínica (NIC), Recessão Gengival (RG)], histológicas (condições inflamatórias do tecido epitelial e conjuntivo) e histométricas (distância entre a margem apical da cavidade e o nível ósseo e entre a extensão apical do epitélio e o nível ósseo) foram realizadas por examinador calibrado e cego. Melhores resultados clínicos (especialmente quanto à PI) e histológicos (epitélio sem alterações e tecido conjuntivo com menor severidade de infiltrado inflamatório) foram observados em associação a sítios restaurados com CIVMR. A avaliação histométrica mostrou menor perda óssea associada a restauração com CIVMR. Todos os sítios SUPRA+ exibiram menor resposta inflamatória. Pode ser concluído que, em cães com periodontite, restaurações subgengivais realizadas com CIVMR, especialmente na presença de controle mecânico de placa supragengival, apresentaram melhor resposta do periodonto quando comparadas com restaurações de amálgama.

Comparison of the palatal connective tissue graft as a membrane with collagen membrane in combination with Bio-Oss and PRGF for the treatment of intrabony defects: a randomized clinical trial

This randomized clinical trial was aimed at comparing the outcomes of palatal connective tissue+ Bio-Oss + PRGF versuscollagen membrane + Bio-Oss+ PRGFin the treatment of intrabny defects. Fifteen patients affected by chronic periodontitis were enrolled. Each patient had at least two intrabonydefect [>/= 3mm]. They were randomly assigned into two groups: patients treated i] with collagen membrane+PRGF+Bio-oss [control group] and ii] with palatal connective tissue as membrane + PRGF+Bio-Oss [experimental group]. Clinical and intrasurgical examinations included probing depth[PD], clinical attachment level[CAL],gingival recession[GR],defect fill[DF], alveolar crest level[AC] and defect resolution[DR] were measured at baseline and after 6 months with re-entry surgery. Statistical analysis was performed usingTwo-way Repeated Measure ANOVA and Wilcoxon. After 6 months, all of the evaluated clinical parameters showed statistically significant changes from baseline within each group [p< 0/05]. The test group showed a significantly smaller amount of gingival recession as compared with control group.[0/8mm versus 1/7mm respectively; P<0/05] But there were not any statistically differences in other clinical parameters between the test and control groups[P>0/05]: pocket depth reduction [3/7mm versus 3/5mm], clinical attachment gain [1/8mm versus 1/6mm], alveolar crest loss [1/8mm versus 1/7mm], defect fill[2/3mm versus 2/2mm] and defect resolution [4/1mm versus3/9mm]. According to the results obtained from this study it can be suggested that clinical effects of application of palatal connective tissue as a membrane and collagen membrane, in combination with Bio-Oss and PRGF in treatment of vertical bone defects, did not have any statistical significant differences except for gingival recession that was statistically smaller in connective tissue group

Calcium phosphate cement as a "barrier-graft" for the treatment of human periodontal intraosseous defects.

Background : Calcium phosphate cements (CPC) are apparently good candidates for periodontal treatment by virtue of their biocompatibility, mouldability and osteoconductivity. However, the clinical efficacy in this regard has not been established. This study is aimed at the evaluation of the efficacy of a formulation of CPC in healing human periodontal intraosseous defects in comparison with hydroxyapatite ceramic granules. Materials and Methods : In this clinical study, 60 patients with periodontal defects were divided into 2 test groups and 1 control group. The defect sites in the test groups were repaired with CPC and hydroxyapatite ceramic granules (HAG). Debridement alone was given in the control group. The progress was assessed at 3, 6, 9 and 12 months observation intervals through soft tissue parameters (probing depth, attachment level and gingival recession). Results: CPC showed significantly better outcome. Probing depth reduction values of CPC, HAG and Control at 6 months were 5.40 ± 1.43, 3.75 ± 1.71 and 2.90 ± 1.48, and those at 12 months were 6.20 ± 1.80, 4.5 ± 1.91 and 2.95 ± 1.73. Clinical attachment gain values of CPC, HAG and Control at 6 months were 5.15 ± 1.50, 3.45 ± 1.96 and 2.25 ± 1.52, and those at 12 months were 5.80 ± 2.02, 3.55 ± 2.06 and 2.30 ± 1.78, In both cases the P value was <0.001 showing high significance. The gingival recession over 12 months, for the CPC group is lesser than that in the HAG group and the value for the control group is marginally higher than both. Soft-tissue measurements were appended by postoperative radiographs and surgical re-entry in selected cases. Conclusions: Calcium phosphate cement is found to be significantly better than hydroxyapatite ceramic granules. The material could be considered as a "barrier-graft".

Láser terapia en el tratamiento de la periodontitis / Laser Therapy in the Periodontitis Treatment

Se realizó un ensayo clínico controlado para evaluar la eficacia del láser de baja potencia combinado con la cirugía parodontal en el tratamiento de las periodontitis en pacientes intervenidos quirúrgicamente por esta afección en la Clínica Norte del municipio Morón de Febrero a Julio de 2006. El universo de trabajo estuvo constituido por todos los pacientes con diagnóstico de periodontitis que en este período de tiempo fueron intervenidos quirúrgicamente en la Clínica Norte del Municipio Morón (N=86), quedando conformada la muestra por 80 pacientes. En los pacientes donde se aplicó la cirugía parodontal combinada con la radiación láser de baja potencia el dolor sólo apareció en un pequeño número de los casos y a las 48 horas ninguno necesitó el uso de analgésicos. A los siete días el mayor porciento de los individuos presentó una cicatrización total de sus tejidos blandos. No aparecieron efectos colaterales al tratamiento. Los pacientes tratados con cirugía parodontal, en su totalidad necesitaron del uso de analgésicos en las primeras 24 horas y aún a las 72 horas después de la cirugía en algunos pacientes; a los siete días el número de pacientes con cicatrización parcial de los tejidos blandos fue elevado aunque predominó la cicatrización total. No hubo ganancia ósea, los pacientes se mantuvieron estables, lográndose sólo detener el proceso. Se encontraron diferencias estadísticamente significativas entre ambos grupos que permiten plantear que el tratamiento del láser de baja potencia en el acto quirúrgico de las periodontitis además de ser fácil de aplicar resultó ser eficaz.

A controlled clinical test was made to evaluate the efficacy of the low power laser combined with the periodontal surgery in the periodontitis treatment in patients with surgical intervention for this affection in the North Clinic of Mor¨®n city from February to July 2006. The universe of work was composed of all patients with periodontitis diagnosis, the ones who had surgical intervention in this period of time in the North Clinic of Mor¨®n city (N=86) getting shaped the sign for 80 patients of any sex who were selected and distributed taking into account the diagnostic criterion at random in two groups according to the diagnostic criteria, the inclusion, exclusion and the pre-established exit. In the studied cases the bigger percent affected for periodontal patients is a member of the masculine sex and they are in the group of 35 and more years. In patients where periodontal surgery combined with the low power radiation laser was applied the pain just appears only in a Little number of the cases and no one needed pain-relievers the next 48 hours. Seven days later the bigger percent of cases showed a total cicatrisation of their soft tissues. In this population an osseous- regeneration signs were seeing in three months from the beginning of the treatment and a year over the 50.00 percent showed somehow osseous profit. Just the minority keeps stable. Moderate periodontitis was predominated in this group and in all cases an answer to the treatment was achieved. In all patients with APP and Love's index ¡Ý 20.00 percent no answer to the treatment was achieved neither in the bigger number of smoker. Collateral effects to the treatment didn't appear. All patients with periodontal surgery needed pain relievers in the first 24 hours and there were some patients that were still maintaining this need to the 72 hours after the surgery...

Etiología y terapia de la periodontitis agresiva: estado actual / Etiology and therapy of aggressive periodontitis: an update

La periodontitis agresiva es una patología de etiología multifactorial que se presenta en pacientes sistémicamente sanos, con rápida pérdida de inserción y ósea, acompañada de agregación familiar. Puede ser localizada o generalizada, siendo las bacterias predominantes el actinobacillus actinomycetemcomitans y la porphyromona gingivalis. Ellas desencadenan una respuesta inmuno-inflamatoria, la cual es la mayor responsable de la gran destrucción tisular. Se ha sugerido que la presencia de virus del tipo herpes pueda jugar un rol importante ne este cuadro. La terapia básica y el mantenimienot son, como en toda la patología gingivo-periodontal, la base del tratamiento. La cirugía reconstructiva y la terapia farmacológica antimicrobiana, han mostrado ser altamente efectivas y de utilización frecuente

Tratamiento periodontal: ¿mecánico, quirúrgico o farmacológico? / Periodontal treatment: mechanical, surgical or pharmacological?

El objetivo del presente estudio es poner de manifiesto los diversos recursos terapéuticos con los que contamos para el tratamiento de la enfermedad periodontal. La destrucción del aparato de sostén del diente, causada por factores etiológicos multifactoriales, requiere en todos los casos de un tratamiento inicial mecánico, independientemente de la técnica que se vaya a emplear. Una vez realizado el mismo, y ante situaciones especiales, podemos recurrir a la terapia complementaria, ya sea ésta quirúrgica o farmacológica. No existe ningún procedimiento de elección, sino lo que el caso requiera. Por lo tanto, las diferentes técnicas para lograr nuestro objetivo no son excluyentes entre sí, sino que se complementan.

The relationship between radiographic and clinical parameters in periodontal maintenance in class II furcation defects

O objetivo deste estudo foi investigar a relação entre medidas clínicas e radiográficas durante a terapia de manutenção periodontal e a confiabilidade de medidas clínicas periodontais repetidas para o diagnóstico precoce de destruição periodontal de lesões de furca classe II. Dezoito lesões de furca classe II em molares inferiores foram incluídas neste estudo. Radiografias padronizadas e medidas do nível clínico de inserção vertical (NCI-v) e da profundidade de sondagem (PS) foram obtidas imediatamente antes do tratamento cirúrgico e aos 6, 12, 18 e 24 meses após a cirurgia. Um total de 72 pares de radiografias foram subtraídos após correção das distorções geométricas e de contraste, e a altura de ganho/perda óssea (AO) (em mm) foi medida. Não houve correlação estatisticamente significante entre NCI-v e AO. Houve uma correlação estatisticamente significante entre redução na PS aos 24 meses e aumento na AO aos 18 meses (r = 0,5, p < 0,05). Os resultados deste estudo sugerem que medidas clínicas e radiográficas refletem diferentes características da reparação e destruição periodontais e medidas clínicas longitudinais repetidas do NCI-v não são confiáveis para o diagnóstico precoce de destruição periodontal em lesões de furca classe II.

Clinical use of enamel matrix derivative proteins [emdogain] in periodontal regeneration

A new product called Emdogain[R] was recently launched in the US by BIORA company for the treatment of intrabony periodontal defects. Emdogain[R] is an enamel matrix protein, which has been demonstrated to be involved in the formation of acellular cementum as well as having the potential to induce regeneration of the periodontium. Clinical studies with Emdogain[R] demonstrated clinical attachment gain and interproximal alveolar bone gain in patients with moderate to severe periodontitis and intrabony pockets. The use and application of Emdogain[R] is described in this article. Studies are being conducted in the US to evaluate the long-term effectiveness of Emdogain[R] in the treatment of intrabony periodontal defects in periodontitis patients

Ganancia de inserción clínica en área de compromiso estético: caso clínico / Ganancia de inserção clínica em área de compromisso estético: caso clínico

Principios de regeneración guiada de tejidos fueron usados con el objetivo de conseguir eliminación de bolsa periodontal persistente luego de procedimientos de raspaje y aplanamiento radicular en área de incisivos centrales superiores. Durante la cirugía de este caso clínico se usó membrana de colágeno y hueso liofilizado bovino; fue lograda la eliminación de la bolsa así como una considerable ganancia de inserción, durante un período de observación clínica y radiográfica de 8 meses. Junto con el relato del caso clínico, se discuten las indicaciones de este tipo de cirugía en áreas de comprometimiento estético

Tratamiento de defectos óseos horizontales en periodoncia con láser Helio - Neón / Treatment of horizontal bone defects in periodontics with the use of helio-neon laser

Se realizó un estudio clínico fase II con 60 pacientes para conocer la eficacia del tratamiento con láser helio-neón en las pérdidas óseas horizontales. Los pacientes se dividieron en 2 grupos de 30: un grupo de estudio, en el que se realizó colgajo Kirkland e irradiación con láser helio-neón en una sola dosis de 3 J/cm² en el acto quirúrgico, y un grupo control al que solamente se le realizó colgajo Kirkland. En las mediciones se utilizaron pie de rey y radiografías periapicales. Se utilizó el equipo Lasermed 101 M de fabricación cubana con potencia de salida de 2MW y fibra óptica. Se aplicó el índice de Love para medir la eficiencia del cepillado. El 100 por ciento de los pacientes con periodontitis simple incipiente tuvieron ganancia ósea parcial, mientras que de los que presentaban periodontitis simple moderada, el 83 por ciento mostró ganancia ósea total en el 10 por ciento del grupo tratado; sin embargo, el grupo control se mantuvo sin cambios en el 100 por ciento. En el índice de Love los pacientes que se mantuvieron estables del grupo que había recibido tratamiento con láser presentaron valores superiores al 20 por ciento. Se concluyó que el tratamiento con láser helio-neón en el acto quirúrgico resultó eficaz

Tratamento periodontal de caso avançado de periodontite adulta / Periodontal treatment of advanced case of adult periodontitis

Uma breve revisäo literária considerando as modalidades terapêuticas do tratamento periodontal justificáveis no presente momento é proposta. A validade da Lei da Ante é discutida com a apresentaçäo de uma breve revisäo de ensaios clínicos mostrando os resultados do tratamento periodontal e protético de casos avançados de periodontite adulta. Um caso é apresentado para ilustrar a possibilidade de manter a saúde periodontal quando os fatores etiológicos estäo sob controle. Algumas consideraçöes reenforçando a importância de outros fatores além das consideraçöes periodontais säo apresentadas e algumas conclusöes importantes säo feitas a fim de alcançar-se os resultados desejados

Prophylactic gingivectomy in arresting the rapidly progressive periodontitis progression

Ten patients suffering from early lesions of RPP, participated in this study. For each patient, the mandibular premolar molar regions were selected randomly, so that, one quadrant was treated with scaling and root planing followed by surgical gingivectomy and the contrary quadrant treated with scaling and root planing alone, in trial to alter the RPP progression, through changing the environmental condition of the causative bacteria. The soft tissue change and alveolar bone level were evaluated clinically and radiographically pre-treatment and at 24 months post-treatment. From this study it was concluded that, early diagnosis of RPP is necessary to stop or delay its progression, complete eradication of early formed periodontal pockets in RPP may retard its progression

Periodontitis del fumador / Smoker's periodontitis

El efecto del hábito de fumar en pacientes con patologías gingivoperiodontales, ha sido seriamente estudiada en los últimos años. A pesar de que la placa bacteriana no difiere en el fumador resoecto del no fumador hay, en cambio, efectos perjudiciales en los mecanismos defensores de la encía, cemento radicular, formación de cálculos, etc. Estas evidencias determinan una terapia con algunas diferencias en relación al tratamiento habitual y un riesgo de recidiva de la lesión más pronunciado que en un paciente no fumador