Periodontal Maintenance Therapy in a Public University: A Six-Year Prospective Study.

BACKGROUND: Few prospective studies have reported results of periodontal status and tooth loss in public/academic periodontal maintenance therapy (PMT) programs. This prospective study aimed to evaluate the periodontal retreatment needs and progression of periodontitis, as well as tooth loss, in individuals under PMT in a public/academic environment. MATERIALS AND METHODS: From a PMT program at a public university, 39 individuals determined to be regular compliers (RC) and 52 irregular compliers (IC) were monitored over the course of 78 months [mean interval between visits of 6.2 ± 0.6 and 13.1 ± 1.9 months, respectively]. Complete periodontal examinations were conducted to evaluate probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) at baseline and final examinations. Biological, demographic, and behavioral predictive risk variables were collected. Univariate and multivariate logistic regressions were performed when appropriate. RESULTS: At final examination, periodontal retreatment needs and progression of periodontitis, as well as tooth loss, were signifi cantly higher among IC when compared to RC (p less than 0.05). Multivariate logistic regression analysis showed that: 1) age and greater than 30% of sites with CAL ≥ 4 mm were associated with the progression of periodontitis; 2) smoking, co-habitation status, family income, and greater than 30% of sites with BOP were associated with periodontal retreatment needs; 3) age, family income, low frequency of tooth brushing, and diabetes were associated with tooth loss. CONCLUSIONS: RC individuals in public or academic PMT programs presented with lower periodontal retreatment needs and progression of periodontitis, as well as tooth loss when compared to IC individuals.

Periodontal risk assessment model in a sample of regular and irregular compliers under maintenance therapy: a 3-year prospective study.

BACKGROUND: The purpose of this study is to investigate the association of the periodontal risk assessment (PRA) model with the recurrence of periodontitis and tooth loss during periodontal maintenance therapy (PMT). METHODS: In a prospective PMT program, 75 regular complier (RC) and 89 erratic complier (EC) patients were selected. A periodontal examination and PRA were performed after active periodontal therapy and after 3 years of PMT. Risk profiles (low, moderate, or high) of participants were evaluated, and the recurrence of periodontitis and tooth loss were analyzed using univariate and multivariate analyses. RESULTS: RCs showed less recurrence of periodontitis and tooth loss than ECs (P <0.05). Rates of periodontitis recurrence in RCs and ECs were 2.7% and 3.4%, respectively, for the moderate-risk profile and 6.7% and 11.2%, respectively, for the high-risk profile. During PMT, 49 teeth (0.65 ± 1.4 teeth per participant) were lost in the RC group, and 70 teeth (0.78 ± 2.1 teeth per participant) were lost in the EC group. High-risk profile participants showed more recurrence of periodontitis and lost significantly more teeth than did participants with moderate- or low-risk profiles in RC and EC groups (P <0.05). CONCLUSION: The risk profile influenced the recurrence of periodontitis and tooth loss. RCs had less recurrence of periodontitis and less tooth loss. The PRA model can be useful in particularizing the risk of patients and adjusting recall intervals.

Prospective study in periodontal maintenance therapy: comparative analysis between academic and private practices.

BACKGROUND: This prospective study aims to evaluate and compare the periodontal status, periodontitis progression, tooth loss, and influence of predictable risk variables of two periodontal maintenance therapy programs over a 12-month period. METHODS: A total of 288 individuals diagnosed with chronic moderate-to-advanced periodontitis, who had finished active periodontal treatment, were evaluated in a public academic environment (AG) (n = 138), as well as in a private clinic (PG) (n = 150). A full-mouth periodontal examination was performed at baseline and at quadrimestral recalls, evaluating plaque index, probing depth, clinical attachment level, furcation involvement, bleeding on probing (BOP), and suppuration. Individuals' social, demographic, and biologic data, as well as compliance with recalls, were recorded. The effect of variables of interest and confounders were tested by univariate and multivariate analysis. RESULTS: The PG demonstrated lower rates of periodontitis progression and tooth loss than did the AG. After adjusting for confounders, the risk variables of BOP (P = 0.047), smoking (P = 0.003), and diabetes (P = 0.028) for the PG and smoking (P = 0.047) for the AG showed a negative influence on periodontal status. CONCLUSIONS: In both groups, the periodontal maintenance therapy minimized the negative effect of the risk variables. However, PG showed significantly less progression of periodontitis and tooth loss compared to AG.

Marcadores séricos e salivares promissores ao diagnóstico da doença periodontal: uma revisão crítica / Serum and salivary promising markers for the diagnosis of periodontal disease: a critical review

A periodontite é uma doença inflamatória que se manifesta clinicamente com a perda dos tecidos de suporte periodontal, incluindo osso alveolar, ligamento periodontal e cemento. O diagnóstico da doença periodontal é realizado através de um conjunto de medidas clínicas, incluindo profundidade de sondagem (PS), nível de inserção clínica (NIC), sangramento a sondagem (SS), índice de placa (IP) e exames radiográficos complementares. No entanto, estas medidas clínicas de DP não predizem o risco em desenvolver a doença e nem sua progressão. Assim, o objetivo desta revisão foi avaliar criticamente os estudos realizados na literatura, com o intuito de mensurar o risco de progressão da doença periodontal, bem como os métodos de coleta preconizados para o estabelecimento do diagnóstico de susceptibilidade à doença periodontal.

Terapia de manutenção periodontal e avaliação do nível de cooperação dos indivíduos / Periodontal maintenance therapy and assessment of the level of compliance of individuals

A doença periodontal é uma condição inflamatória dos tecidos periodontais. É caracterizada pela destruição progressiva dos tecidos que suportam o dente na cavidade bucal. Sendo consenso que inúmeros fatores podem influenciar na progressão e/ou gravidade desta doença. Além disso, são infecções com alto potencial para recorrência e, eventualmente, perda dentária. A terapia periodontal objetiva controlar e/ou eliminar a etiologia microbiana e os fatores de riscos contribuintes para susceptibilidade e gravidade da periodontite, impedindo a progressão e a recorrência da doença, preservando a dentição em estado de saúde, conforto e função com estética. A terapia de manutenção periodontal (TMP) é uma parte integrante da terapia, iniciada após a terapia periodontal ativa ser completada em intervalos que variam de acordo com a condição e o risco de cada indivíduo. Outro fator importante a considerar em relação a periodicidade é o nível de controle do biofilme dental do indivíduo, ou seja, quanto menor este controle, menor deve ser o intervalo para a rechamada. Entretanto, sabe-se que indivíduos com doenças crônicas tendem a cooperar pobremente, especialmente se a doença não é percebida de forma ameaçadora, se a terapia consome tempo ou se os sintomas não são perturbadores. Assim, o objetivo desta revisão foi avaliar criticamente os estudos realizados com o intuito de avaliar o grau de cooperação dos indivíduos durante a TMP.

Clinical Evidence of the Efficacy of a Mouthwash Containing Propolis for the Control of Plaque and Gingivitis: A Phase II Study.

The aim of this study was to evidence the clinical efficacy of an alcohol-free mouthwash containing 5.0% (W/V) Brazilian green propolis (MGP 5%) for the control of plaque and gingivitis. Twenty five subjects, men and women aging between 18 and 60 years old (35 ± 9), were included in a clinical trials phase II study who had a minimum of 20 sound natural teeth, a mean plaque index of at least 1.5 (PI), and a mean gingival index of at least 1.0 (GI). They were instructed to rinse with 10 mL of mouthwash test for 1 minute, immediately after brushing in the morning and at night. After 45 and 90 days using mouthwash, the results showed a significant reduction in plaque and in gingival index when compared to samples obtained in baseline. These reductions were at 24% and 40%, respectively (P < .5). There were no important side effects in soft and hard tissues of the mouth. In this study, the MGP 5% showed evidence of its efficacy in reducing PI and GI. However, it is necessary to perform a clinical trial, double-blind, randomized to validate such effectiveness.

Tooth loss in individuals under periodontal maintenance therapy: prospective study.

This prospective study aimed to evaluate the incidence, the underlying reasons, and the influence of predictors of risk for the occurrence of tooth loss (TL) in a program of Periodontal Maintenance Therapy (PMT). The sample was composed of 150 complier individuals diagnosed with chronic moderate-severe periodontitis who had finished active periodontal treatment and were incorporated in a program of PMT. Social, demographic, behavioral and biological variables were collected at quarterly recalls, over a 12-month period. The effect of predictors of risk of and confounding for the dependent variable TL was tested by univariate and multivariate analysis, as well as the underlying reasons and the types of teeth lost. During the monitoring period, there was a considerable improvement in periodontal clinical parameters, with a stability of periodontal status in the majority of individuals. Twenty-eight subjects (18.66%) had TL, totaling 47 lost teeth (1.4%). The underlying reasons for TL were: periodontal disease (n = 34, 72.3%), caries (n = 3, 6.4%), prosthetic reasons (n = 9, 19.2%), and endodontic reasons (n = 1, 2.1%). Additionally, subjects with 10% of sites with probing depth between 4 and 6 mm were 5 times more likely to present TL (OR = 5.13, 95% CI 2.04-12.09). In this study, the incidence of TL was small and limited to few individuals. Additionally, gender and severity of periodontitis were significantly associated with TL during the monitoring period.

Tooth loss in individuals under periodontal maintenance therapy: prospective study

This prospective study aimed to evaluate the incidence, the underlying reasons, and the influence of predictors of risk for the occurrence of tooth loss (TL) in a program of Periodontal Maintenance Therapy (PMT). The sample was composed of 150 complier individuals diagnosed with chronic moderate-severe periodontitis who had finished active periodontal treatment and were incorporated in a program of PMT. Social, demographic, behavioral and biological variables were collected at quarterly recalls, over a 12-month period. The effect of predictors of risk of and confounding for the dependent variable TL was tested by univariate and multivariate analysis, as well as the underlying reasons and the types of teeth lost. During the monitoring period, there was a considerable improvement in periodontal clinical parameters, with a stability of periodontal status in the majority of individuals. Twenty-eight subjects (18.66 percent) had TL, totaling 47 lost teeth (1.4 percent). The underlying reasons for TL were: periodontal disease (n = 34, 72.3 percent), caries (n = 3, 6.4 percent), prosthetic reasons (n = 9, 19.2 percent), and endodontic reasons (n = 1, 2.1 percent). Additionally, subjects with 10 percent of sites with probing depth between 4 and 6 mm were 5 times more likely to present TL (OR = 5.13, 95 percent CI 2.04-12.09). In this study, the incidence of TL was small and limited to few individuals. Additionally, gender and severity of periodontitis were significantly associated with TL during the monitoring period.

Phase II study with mounthrinse containing 5% of propolis for three-months: compliance, appreciation and acceptability of the product / Estudo fase II com colutório contendo própolis 5%: aderência, apreciação e aceitabilidade do produto

A placa dentária é considerada um fator etiológico chave associado a gengivite decorrente. A sua remoção pode ser difícil em pacientes que possuam coordenação motora deficiente ou quaisquer outros problemas. Então, ouso do bochecho como adjunto da escovação no controle da placa bacteriana e da gengivite pode aumentar os benefícios no controle de placa dental. Um estudo de fase II foi utilizado para avaliar a aderência, a apreciação e a aceitabilidade de um enxaguatório bucal sem álcool contendo 5% de própolis verde (EPV 5%) no controle de placa e gengivite durante três meses. Cada indivíduo, ao final do estudo, respondeu a um questionário sobre a apreciação e aceitabilidade do enxaguante bucal. Vinte e um pacientes completaram o estudo, apesar de a maioria deles terem considerado o sabor do EPV 5% desagradável. Eles ficaram satisfeitos com o produto e apontaram as mudanças positivas na saúde bucal após o período de tratamento. Sendo assim, a adesão foi satisfatória (≥80%) sem diferença estatisticamente significante entre os períodos de bochecho da manhã da noite.

Dental plaque is considered a key etiological factor associated with arising gingivitis. Its removal can be difficult in pacients with lack of coordination or any other problems. Then, the use of mouthrinse as adjunct to toothbrushing in control of plaque and gingivitis might increase the benefits of controlling dental plaque. A phase II study was used to evaluate the compliance, appreciation and acceptability of an alcohol-free mouthwash contain 5% green propolis (MGP 5%) in control of plaque and gingivitis for three months. Each subject, at the end of the study, answered a questionnaire about appreciation and acceptance of the mouthwash. Twenty one subjects completed the study, although most of them felt the taste of MGP 5% unpleasant. They were satisfied with the product, pointing positive changes in the oral health after the treatment period. Then, the compliance was satisfactory (≥ 80%) with no statistically significant difference between the periods of rinsing in the morning and at night

Prospective study of complier individuals under periodontal maintenance therapy: analysis of clinical periodontal parameters, risk predictors and the progression of periodontitis.

AIM: This prospective study aimed to evaluate the progression of periodontitis and the influence of risk variables among individuals attending a programme of periodontal maintenance treatment in an academic environment. MATERIAL AND METHODS: A total of 150 individuals diagnosed with chronic moderate-advanced periodontitis, and who had finished active periodontal treatment, were incorporated into the periodontal maintenance therapy. Social, demographic and biological variables of interest from subjects were collected at quarterly recalls, over a 12-month period. The effect of variables of interest and confounding on the periodontal status and progression of periodontitis was tested by univariate and multivariate logistic analysis. RESULTS: A total of 130 subjects (86.7%) showed stable periodontal status, whereas 20 subjects (13.3%) presented periodontitis progression. Twenty-eight subjects (18.66%) presented tooth loss that resulted in a total of 47 lost teeth (1.38%). Diabetes was not found to be associated with periodontitis progression (p=0.67). Smoking was significantly associated with a greater progression of periodontitis (OR=2.7, 95% CI 1.01-7.22). CONCLUSIONS: Periodontal maintenance programmes in academic environment can stabilize the periodontal condition obtained after active periodontal therapy as well as control the action of risk variables for the progression of periodontitis.

Estudo coorte prospectivo em terapia de manutenção periodontal: análise de parâmetros clínicos periodontais, progressão de periodontite, perda dentária e de modelo multifuncional para avaliação do risco periodontal / Prospective cohort study in periodontal maintenance therapy: analysis of clinical periodontal parameters, progression of periodontitis, tooth loss and multifunctionmodel for periodontal risk assessment

Este estudo de coorte aberto prospectivo teve como objetivo avaliar a progressão da periodontite, a influência de variáveis preditoras de risco e avaliar a incidência e motivos para a ocorrência de perda dentária (PD) em indivíduos inseridos num programa de terapia de manutenção periodontal (TMP) em ambiente universitário. Metodologia: 250 indivíduos com diagnóstico de periodontite crônica moderadaavançada, que finalizaram terapia periodontal ativa foram recrutados na Faculdade de Odontologia da Universidade Federal de Minas Gerais, Brasil. Todos foram submetidos a um exame clínico periodontal completo (TMP1) e a uma coleta de variáveis sociais, demográficas e biológicas de interesse. Avaliou-se o grau de cooperação destes indivíduos (cooperadores, cooperadores irregulares e não cooperadores) quanto à adesão ao programa de TMP em re-chamadas trimestrais (TMP2, TMP3 e TMP4) pelo período de 12 meses. Assim, 150 indivíduos considerados cooperadores completos (60%) foram elegíveis para esta pesquisa. Em todas as re-chamadas foram coletados os seguintes dados: índice de placa (IP), sangramento a sondagem (SS), profundidade de sondagem (PS), níveis clínicos de inserção (NCI), supuração (S) e envolvimento de furca (EF), em todos dentes presentes (com exceção de terceiros molares). Identificou-se, pela plausibilidade biológica, quais variáveis preditoras de risco poderiam influenciar a condição clínica periodontal e a progressão da periodontite. O efeito de variáveis de interesse e confundimentofoi testado por análise univariada e regressão logística multivariada, assim como motivos e tipos de dentes perdidos. Resultados: Observou-se uma melhora considerável nos parâmetros clínicos periodontais na maioria dos indivíduos. Durante o período de monitoramento, 130 indivíduos (86,7%) tiveram estabilidade periodontal e 20 indivíduos (13,3%) apresentaram progressão de periodontite. Diabetes não foi associada à progressão de periodontite (p=0,67) e o tabagismo foi significantemente associado a maior progressão de periodontite (RC=2,7; 95% IC: 1,01-7,22). 28 indivíduos (18,66%) apresentaram perda dentária os quais somaram 47 dentes perdidos (1,4%). Os motivos e números de dentes perdidos foram respectivamente: doença periodontal (n=34; 72,3%), cárie (n=3; 6,4%), motivos protéticos (n=9; 19,2%), perfuração radicular (n=1; 2,1%). Molares apresentaram maior mortalidade dental do que não molares e homens 3 vezes mais chances de PD do que mulheres (RC=3,16; 95% IC: 1,28-7,78). Indivíduos com 10% de sítios com PS entre 4 e 6 mm apresentaram 5 vezes mais chances de PD (RC= 5,13; IC 95%: 2,04-12,09). A determinação do risco individual pelo modelo ARP (Avaliação do Risco Periodontal) resultou na classificação dos indivíduos em 02(1,3%) de baixo risco, 83 (55,3%) de moderado risco e 65 (43,4%) de alto risco àrecorrência de periodontite. Conclusões: Os programas de manutenção periodontalem ambiente universitário podem estabilizar a condição periodontal obtida apósterapia ativa e, adicionalmente, controlar e/ou minimizar a ação de variáveispreditoras de risco a progressão da periodontite. Neste estudo, a incidência de PDfoi pequena e restrita a poucos indivíduos. A adoção do modelo ARP contribui para adeterminação do risco individual dos indivíduos, permitindo que os escores de riscosejam comparados ao longo do tempo. Assim, este instrumento pode ser válido paramonitorar particularmente variáveis mutáveis de risco e auxiliar na estratégia,determinação e cooperação nos programas de TMP. A estabilidade dos tecidosperiodontais, controle de variáveis de risco e redução da PD podem ser metasalcançáveis pelos programas de TMP, refletindo a sua eficiência e propiciandomelhor qualidade de vida para indivíduos periodontalmente susceptíveis

This open prospective cohort study aimed to evaluate the progression of periodontitisand, in addition, the incidence, the reasons and the role of risk predictors on theoccurrence of tooth loss (TL) in individuals inserted in a program of periodontalmaintenance therapy (PMT) in academic environment. Methods: 250 individualsdiagnosed with moderate/advanced chronic periodontitis, that had finished activeperiodontal therapy, in the Faculty of Dentistry of the Federal University of MinasGerais, Brazil, were selected. Individuals were submitted to a complete clinicalperiodontal examination (PMT1) and collection of social, demographic and biologicalvariables of interest was performed. The degree of compliance of these individuals,(compliers, irregular compliers and non compliers) according to the adhesion to theTMP program in quarterly recalls (PMT2, PMT3 and PMT4), was evaluated during 12months period. A total of 150 individuals, that were considered complete compliers(60%), became eligible for this study. In the recall visits, the following data werecollected for all teeth (with exception of third molars): plaque index (PI), bleeding onprobing (BOP), probing depth (PD), clinical attachment level (CAL), suppuration (SU)and furcation involvement (FI). It was identified, according to the biologicalplausibility, which risk predictors could influence the periodontal clinical condition andthe progression of the periodontitis. The effect of variables of interest andconfounding was tested by univariate analysis and multivaried logistic regression, aswell as the reasons and types of teeth that were lost. Results: A considerableimprovement in periodontal clinical parameters was observed in the majority of theindividuals. During the monitoring, 130 individuals (86.7%) showed periodontalstability and 20 individuals (13.3%) presented periodontitis progression. Diabeteswas not associated with periodontitis progression (p=0.67) and, in contrast, smokingwas significantly associated with periodontitis progression (OR=2.7; 95% IC 1.01-7.22). 28 individuals (18.66%) presented TL, resulting in a total of 47 lost teeth(1.4%). The reasons and numbers of tooth loss and numbers were, respectively:periodontal disease (n=34; 72.3%), caries (n=3; 6.4%), prosthetic reasons (n=9;19.2%), root perforation (n=1; 2.1%). Molars presented greater tooth mortality thannon molars and men presented 3 times more odds of TL than women (OR=3.16;95% IC: 1.28-7.78). Additionally, individuals with 10% of sites with PD between 4 and6mm presented 5 times more odds of TL (OR= 5.13; IC 95%: 2.04 ­ 12.09). Theperiodontal risk assessment (PRA) resulted in the classification of individuals in 02(1.3%) low risk, 83 (55.3%) moderate risk and 65 (43.4%) of high-risk for recurrenceof periodontitis. Conclusions: The programmes of periodontal maintenance inacademic environment can stabilize the periodontal condition obtained after activetherapy, additionally to control and/or minimize the action of risk predictors on theprogression of periodontitis. In this study, the TL incidence was small and restrictedto few individuals. The adoption of the model PRA contributes to the determination ofrisk of individuals allowing the risk scores are compared over time. So, thisinstrument can be particularly monitoring changeable risk predictors and assisting inthe strategy, determination and compliance in the PMT programs. The stability ofperiodontal sites, the control of risk predictors and the reduction of TL can bepredictable goals for the PMT programs, reflecting its effectiveness and betterimproving quality of life for individuals susceptible to periodontitis

Association between maternal periodontitis and an increased risk of preeclampsia.

BACKGROUND: Periodontal disease has been considered a systemic exposure implicated in a higher risk of adverse pregnancy outcomes. The aim of the present study was to determine whether maternal periodontitis is associated with an increased risk of preeclampsia. METHODS: A case-control study was conducted in a public hospital in Belo Horizonte, Brazil. During the study period, 588 women, aged 14 to 46 years, were deemed eligible and had data available for analysis. Maternal demographic and medical data were collected from medical records. Preeclampsia was defined as blood pressure >140/90 mm Hg and > or =1+ proteinuria after 20 weeks of gestation. A periodontal examination was performed postpartum. Maternal periodontitis was defined as the presence of four or more teeth with one or more sites with a probing depth > or =4 mm and clinical attachment loss > or =3 mm at the same site. The effects of maternal age, chronic hypertension, primiparity, smoking, alcohol use, and number of prenatal visits were analyzed. Adjusted odds ratios (ORs) for preeclampsia were calculated using multivariate logistic regression. RESULTS: The prevalence of periodontitis was 63.9% and preeclampsia was 18.5%. Variables associated with preeclampsia were chronic hypertension (OR = 4.10; 95% confidence interval [CI] = 2.0 to 8.4; P = 0.001), primiparity (OR = 2.40; 95% CI = 1.5 to 3.9; P = 0.004), maternal age (OR = 1.07; 95% CI = 1.0 to 1.1; P = 0.001), and maternal periodontitis (OR = 1.88; 95% CI = 1.1 to 3.0; P = 0.001). CONCLUSION: Maternal periodontitis was determined to be associated with an increased risk of preeclampsia.

Terapia periodontal de suporte / The supportive peridontal therapy

O objetivo deste estudo é o de se inteirar da importância e da conduta da Terapia Periodontal de Suporte na clínica dos Periodontistas da cidade de Belo Horizonte. Minas Gerais, Brasil. Enviou-se um questionário a 71 especialistas, dos quais foram computados, 49, com perguntas pertinentes à freqüência, aos parâmetros clínicos adotados para determinar periodicidade e procedimentos, a estimativa do número de pacientes que retornam à esta terapia, a porcentagem de retorno e as razões prováveis para o não retorno, além dos recursos utilizados para a motivação dos seus pacientes. Procedeu-se a uma revisão de literatura dos últimos 15 anos, referentes à manutenção periodontal. Conclui-se que a Terapia Periodontal de Suporte é considerada indispensável (98 por cento) e faz parte da rotina clínica dos periodontistas de Belo Horizonte (98 por cento). Constatou-se que os parâmetros clínicos mais utilizados são: alterações na profundidade de sondagem, sangramento à sondagem e perda de inserção clínica. A freqüência média de rechamada dos pacientes variou entre três e seis meses. A maior percentagem dos entrevistados considera que 50-75 por cento dos seus pacientes retornam e atribiu o não retorno, principalmente, ao alto custo da Terapia Periodontal de Suporte (25 por cento) e à falta de motivação do paciente (26 por cento).

Avaliação da atividade blastogênica em células mononucleares de pacientes portadores de periodontite do adulto sob a estimulação com fitohemoaglutinina / Blastogenic activity of mononuclear cells in patients with adult periodontitis stimulated by PHA

A Doença Periodontal Inflamatória Crônica (DPIC) é uma doença de etiologia bacteriana, caracterizada por alterações no mecanismo imunorregulador. Avaliamos a atividade blastogênica de células mononucleares de pacientes portadores de Periodontite do Adulto sob a estimulação com fitohemoaglutinina. Os resultados demonstraram uma diminuição da atividade blastogênica nos pacientes comparada aos voluntários controles saudáveis (p<0.05). A relação desta imunodepressão celular com a imunopatogênese da DPIC é discutida