Problem-based education for the diagnosis and management of ankyloglossia by dentists in Primary Care

Abstract

The Maguerez Arch promotes problem-based education, bringing individuals closer to their reality and encouraging reflective practice for transformation. In this context, a theoretical-practical gap was observed in the diagnosis of ankyloglossia and in the assessment of breastfeeding for performing frenotomy/frenectomy in infants by primary care dentists. This study reports the experience of problem-based education in a Primary Health Care Unit, aiming to strengthen the diagnosis and management of ankyloglossia in newborns and infants. The five stages of the Maguerez Arch were applied, including theoretical and practical activities, as well as evaluations and clinical demonstrations of the surgical procedure. At the end, all participants were considered competent to apply the Bristol protocol criteria and the Coryllos classification, and self-declared able to perform the procedure. The methodology proved effective in professional qualification and in promoting changes in clinical practice.

Key-words
Primary health care; Ankyloglossia; Dentists; Health Education

Resumo

O Arco de Maguerez promove a educação problematizadora, aproximando o sujeito de sua realidade e incentivando a prática reflexiva para a transformação da realidade. Nessa perspectiva, observou-se uma lacuna teórica-prática no diagnóstico de anquiloglossia e avaliação da mamada para realização de frenotomia/frenectomia em bebês por cirurgiões-dentistas da Atenção Básica. Este estudo relata a experiência da educação problematizadora em uma Unidade Básica de Saúde, visando fortalecer o diagnóstico e manejo da anquiloglossia em recém-nascidos e bebês. Foram aplicadas as cinco etapas do Arco de Maguerez, com atividades teóricas e práticas, incluindo avaliações e demonstrações clínicas do procedimento cirúrgico. Ao final, todos os participantes foram considerados aptos a utilizar os critérios do protocolo Bristol e a classificação Coryllos, além de se autodeclararem capazes de realizar o procedimento. A metodologia se mostrou eficaz na qualificação profissional e na promoção de mudanças na prática clínica.

Palavras-chave
Atenção Básica; Anquiloglossia; Cirurgiões-dentistas; Educação em saúde

Resumen

El Arco de Maguerez promueve la educación problematizadora, aproximando al sujeto de su realidad e incentivando la práctica reflexiva para la transformación. Bajo esta perspectiva, se observó una laguna práctica-teórica en el diagnóstico de la anquiloglosia y evaluación del amamantamiento para la realización de frenotomía / frenectomía en bebés por parte de los cirujanos-dentistas de la atención básica. Este estudio relata la experiencia de la educación problematizadora en una Unidad Básica de Salud, con el objetivo de fortalecer el diagnóstico y el manejo de la anquiloglosia en recién nacidos y bebés. Se aplicaron las cinco etapas del Arco de Maguerez con actividades teóricas y prácticas, incluyendo evaluaciones y demostraciones clínicas del procedimiento quirúrgico. Al final, todos los participantes de consideraron aptos para utilizar los criterios del protocolo Brasil y la clasificación Coryllos, además de autodeclararse capaces para realizar el procedimiento. La metodología se mostró eficaz en la calificación profesional y en la promoción de cambios en la práctica clínica.

Palabras clave
Atención básica; Anquiloglosia; Cirujanos-dentistas; Educación en salud

Introduction

Approaches that value dialogue and the active participation of professionals are essential for knowledge construction in the health education process^1,2. However, deconstructing the traditional teaching model and overcoming fragmentation oriented toward specialties remain challenges^2,3. Thus, the incorporation of active methodologies fosters critical and reflective professional training, conducive to discussion and integration between theory and practice⁴.

The problematization methodology, through the Maguerez Arc, is part of active methodologies, enhancing the planning of continuing health education (CHE) actions^1,2,5,6. By adopting a democratic and dialectical-reflective logic, it brings individuals closer to their real-life context, encouraging reflection, planning, and transformation of reality^3,5,7.

Considering that the Family Health Strategy (FHS) model transcends the mere technical understanding of the health-disease process, Primary Health Care (PHC) must consider the uniqueness of individuals and the context in which they are inserted, aiming at comprehensive care^8,9. In this way, it should be resolutive, person-centered, capable of solving most health issues and coordinating care⁸.

Breastfeeding is the first contact of human beings with adequate nutrition and is essential for maternal health, survival, nutrition, and child development^10,11. It contributes to the growth and development of the mandible, face, and oral cavity^12-14, stimulating speech and oral musculature, and favoring the proper development of the craniofacial complex¹⁵.

Despite its benefits, difficulties such as poor latch or short lingual frenulum are common¹⁵, requiring support from the health team^12,16. In Brazil, the prevalence of exclusive breastfeeding among children under 6 months is 41%¹⁷, below the WHO recommendation¹¹.

Studies have demonstrated the relationship between ankyloglossia and breastfeeding^18-21 and have indicated that ankyloglossia may negatively interfere with breastfeeding, affect latch and proper suction, cause pain, and lead to reduced stimulation of milk production—directly related to suction stimulus—and breast drainage²². The symptom most commonly associated with ankyloglossia is difficulty in breastfeeding due to pain, poor latch, or insufficient suction²³.

Contemporary research shows that treatment through frenotomy or frenectomy significantly contributes to cases in which ankyloglossia causes breastfeeding difficulties, improving latch, relieving pain, and increasing maternal comfort, allowing infants to obtain more milk during feeding^24-27. A recent systematic review and meta-analysis (2024) showed that after frenotomy in infants with breastfeeding difficulties and a diagnosis of ankyloglossia, breastfeeding self-efficacy, latch, and pain improved significantly²⁷.

Another systematic review²⁸ highlighted that evidence on whether treatment improves breastfeeding is conflicting. However, it concluded that frenotomy in infants is effective in improving breastfeeding difficulties and maternal pain and may improve breastfeeding outcomes. Another systematic review²⁹ found that frenotomy reduced maternal nipple pain in the short term but emphasized that definitive benefits remain unproven due to risk of bias, reinforcing the need for high-quality randomized clinical trials.

Despite the mandatory assessment of the lingual frenulum in infants in all hospitals and maternity units in Brazil³⁰, there is a gap in the literature regarding the training of dental surgeons within the Brazilian National Health System (SUS) on this topic.

This study aims to highlight perceptions and contradictions in dental practices in Primary Health Care, grounded in the theoretical assumptions of the problematization methodology^1-4, through an experience report of applying the Maguerez Arc as a CHE strategy to strengthen the diagnosis of ankyloglossia and breastfeeding assessment for frenotomy/frenectomy in newborns and infants in Primary Health Care, in a primary health care unit in the Northern Region of the Federal District, highlighting its potential for replication based on the contents of Technical Note No. 35/2018²².

Method

This is an experience report developed by a dental resident (facilitator) from the Multiprofessional Residency Program in Family and Community Health at the School of Health Sciences (ESCS), who used the problematization methodology to promote CHE practices.

This methodology involves five stages: observation of reality; identification of key points; theorization; hypothesis of solution; and practical application, involving planning and execution of knowledge^1,5,7.

The primary health care unit studied has ten Family Health teams (FHTs), covering more than 40,000 people. According to Ordinance Nº 77/2017, it is classified as a type II unit³¹. The territory presents geographic, social, historical, and political diversity². It has six Oral Health teams (OHTs), modality I (one dental surgeon and one oral health assistant or technician), in addition to a Multiprofessional team (e-MULTI)⁸. The OHTs work in the same shared environment, totaling six dental surgeons, six technicians, and four dental offices.

The methodology (Figure 1) was applied from October 2023 to March 2024 (Figure 2), during in-service education activities of the Multiprofessional Residency Program in dental care within Primary Health Care in a unit in the Northern Region of the Federal District. The proposal was approved by local PHC management and divided into two axes: theoretical and practical. The theoretical axis took place in February 2024 due to the need to align professionals’ schedules.

Figure 1
Stages of the Maguerez Arc.

Figure 2
Schedule.

Table 1
Theoretical Axis Planning: topics addressed..

1	Introduction to the topic
2	Importance of frenotomy in positive cases of ankyloglossia associated with breastfeeding difficulties
3	Presentation of current literature
4	Patient care flow defined by the Ministry of Health
5	Presentation of protocols available in the literature
6	Technical Note No. 35/2018
7	Educational activity for use of the Bristol protocol
8	Case series
9	Technical Note No. 40/2023 from the Federal District State Health Department (SES-DF)
10	Frenotomy technique
11	Breastfeeding assessment
12	Latch adjustment

• Source: Prepared by the authors.

The content of the theoretical axis was planned according to Table 1. During the planning process, audiovisual theoretical material was developed to foster discussion based on current literature, guidelines from the Brazilian Ministry of Health and the Federal District Health Department (SES-DF), as well as the ideal flow of care and referrals, and the use of the Bristol Tongue Assessment Tool (BTAT). All theoretical planning was carried out by the facilitator under the supervision of the residency preceptor.

The practical axis was developed in the clinical routine, according to demand, from November 2023 to March 2024, with joint assessments using BTAT—recommended by the Ministry of Health—and breastfeeding observation, in addition to demonstration of the surgical procedure by the facilitator.

It was previously agreed with the Oral Health teams and local management to reserve a moment for discussion and participatory reflection on current protocols related to the topic. CHE actions were always conducted by the same facilitator.

According to Resolution Nº 510/16 of the National Health Council, this study was not submitted to a Research Ethics Committee, as no participant data were used³².

The theoretical meeting took place in the unit auditorium, lasting 1 hour and 30 minutes, bringing together six dental surgeons and one oral health technician. The objective was to promote active discussion and encourage the matrix support approach among teams. Mediation was conducted by the facilitator. In the final stage, participants analyzed photographs and videos, classifying them according to BTAT and breastfeeding assessment, and were encouraged to discuss.

Since the purpose of using the Arc is to promote continuing health education (CHE), the evaluation instrument of the meeting was informal, based on the facilitator’s perception of the discussions and on the scores (BTAT) assigned by professionals to the photographs and videos presented using previously developed theoretical and audiovisual material. The theoretical axis occurred as described in the planning.

Results and discussion

The results and discussion follow the logic of the five stages of the Maguerez Arc⁵.

Observation of reality

In this stage, the resident carefully observed reality to identify limitations of the Oral Health teams^5,33, as reported by professionals and/or local management.

The Oral Health teams share four dental offices; however, dental reception is disconnected from the unit, revealing fragmentation. Each Oral Health team is linked to a Family Health team, with joint meetings and a shared assigned territory. Nevertheless, there is no reserved space for continuing health education or meetings among dental surgeons, with care demands prevailing over planning, as highlighted by Coelho et al.².

Despite particularities in the work process, according to the professionals themselves, all cases of ankyloglossia were referred to Secondary Care, evidencing a lack of theoretical-practical knowledge regarding diagnosis and procedure, considering that the Federal District Health Department, in Technical Note Nº 40/2023, recommends referral only in exceptional cases.

Thus, a theoretical-practical gap was identified in the diagnosis of ankyloglossia and breastfeeding assessment, leading to the following questions based on the observed reality:

1. How can discussion spaces among Oral Health teams be strengthened?

2. How can overcoming the referral-based logic be encouraged?

Key points

After critical analysis of reality, the main aspects related to the problem were identified^5,33:

1. Theoretical gap in the diagnosis of ankyloglossia;

2. Insufficient knowledge of protocols, recommendations, and technical notes;

3. Technical-practical deficiency in performing frenotomy/frenectomy;

4. Predominance of a referral culture rather than problem-solving within Primary Health Care.

Theorization

This stage involves the search for relevant theoretical foundations regarding the observed reality to enable its transformation^5,33. Thus, a search for evidence and theoretical references was conducted in the available literature, including scientific articles, technical notes, and Brazilian legislation, in order to improve discussion, promote reflection, and support the formulation of possible solution hypotheses.

The Family Health Strategy model enables a break from the referral logic without accountability for families⁹. Its perspective goes beyond the mere technical understanding of the health-disease process⁹. Therefore, it is necessary to discontinue the biomedical model logic, still prevalent in healthcare, professional training, and in the perception of health in its broader sense⁹.

Ankyloglossia is a congenital condition or anomaly that can be identified at birth and occurs due to the persistence of a small portion of embryonic tissue of the lingual frenulum that should have undergone apoptosis during embryonic development^18,20-23.

It is characterized by a short and thick or thin lingual frenulum²². Anatomical aspects vary, including thickness, elasticity, and the region where the frenulum attaches to the tongue and the floor of the mouth²². Ankyloglossia may be mild, partial (most common), severe, or complete—when the tongue is fused to the floor of the mouth²².

Ankyloglossia causes limitation of tongue movement to varying degrees^18,20 and may lead to several oral developmental problems, breastfeeding difficulties, feeding issues, speech alterations, swallowing disorders, and related problems^18,24,26. At the same time, breastfeeding requires well-defined tongue peristalsis (from front to back) and synchronization between tongue and palate²⁴.

According to Macau-Lopes et al.³⁴, dental surgeons were the professionals who most frequently performed surgical procedures (frenotomy/frenectomy) in the Brazilian Unified Health System between 2013 and 2017. Additionally, 33% of these procedures were performed in Primary Health Care by dental surgeons³⁴.

Frenotomy consists of a simple incision using blunt-ended scissors and is a simple, safe, and effective surgical procedure^24,35. A topical anesthetic may be applied to each side of the frenulum with a cotton swab, usually topical benzocaine. Immediately after the procedure, the infant should be returned to the breast, and latch adjustment should be performed. Maternal comfort is usually immediate²⁴.

However, surgical treatment should be indicated with caution²⁶, that is, only in cases with real indication. According to the Brazilian Ministry of Health, the conduct must always consider whether the condition interferes with breastfeeding, associated with the test result²². On the other hand, several authors agree that symptomatic cases of ankyloglossia should be treated as early as possible, as it is a basic condition for feeding and can significantly improve breastfeeding outcomes^18,24,27.

The Lingual Frenulum Assessment Protocol in Infants is mandatory in all hospitals and maternity units in Brazil³⁰. According to the Brazilian Ministry of Health, in cases of suspicion or confirmed diagnosis with protocol application, breastfeeding assessment, and presence of breastfeeding problems, the patient will be discharged from the maternity unit and referred to the reference primary health care unit within the first week of life. If necessary, referral may be made to Human Milk Banks, Specialized Rehabilitation Centers, or specialty outpatient clinics²². However, if the test result is confirmed and/or breastfeeding difficulties are present, surgical intervention should be considered in the maternity unit itself or another service within the Health Care Network²².

However, there is no consensus in the literature regarding the most appropriate test or diagnostic protocol for identifying and characterizing ankyloglossia^22,23. Several protocols may be used, including Bristol, Coryllos, Martinelli, Kotlow score, Hazelbaker assessment, among others²³.

In Brazil, the Brazilian Ministry of Health issued Technical Note Nº 35/2018²² to comply with Law Nº 13,002 of June 20, 2014³⁰, to guide professionals and health services regarding early identification of ankyloglossia in newborns and to establish care flow within the Health Care Network, due to its potential interference with breastfeeding.

This Technical Note primarily considered ease of application in choosing the protocol and recommends the use of the Bristol Tongue Assessment Tool. According to the literature, it is the most widely used assessment tool worldwide²³. The protocol is divided into four main categories: (1) appearance of the tongue tip; (2) attachment of the frenulum to the lower gum ridge; (3) tongue elevation; (4) tongue protrusion. Each aspect is scored from 0 to 2. The total score ranges from 0 to 8: scores 0–3 indicate impaired tongue function, 4–5 indicate doubtful diagnosis, and 6–8 indicate negative diagnosis for ankyloglossia²².

Although the Brazilian Ministry of Health recommends this protocol, the Federal District Health Department uses the Coryllos classification as a parameter to justify referrals to Secondary Care (Technical Note Nº 40/2023). The Coryllos classification is divided into four main categories (types): 1) attachment of the frenulum to the tip of the tongue, usually in front of the alveolar ridge in the lower lip sulcus; 2) attachment of the frenulum two to four millimeters from the tip of the tongue and attachment at or immediately behind the alveolar ridge; 3) attachment in the middle of the tongue and in the middle of the floor of the mouth, being more restricted and less elastic; 4) attachment of the frenulum against the base of the tongue, being thick, shiny, and inelastic²⁴. Coryllos²⁴ considers types 1 and 2 to be more common and easier to visualize, whereas types 3 and 4 are considered less common and more difficult to visualize, therefore having a greater likelihood of remaining untreated²⁴.

However, the Coryllos classification does not describe how the scoring system was developed, the number of infants examined, the validation method, or evidence of reliability²³.

It´s important to highlight that any trained health professional may perform lingual frenulum assessment³⁶. However, only dental surgeons and doctors are authorized to perform the surgical procedure³⁶.

De Queiroz et al.³⁷ found that more than 90% of dental surgeons were aware of regulations for lingual frenulum assessment and concluded that most are capable of diagnosis and clinical decision-making. Therefore, the importance of the dentist in the assessment of the lingual frenulum and clinical management is highlighted³⁴.

Penha et al.³⁶ and Macau-Lopes et al.³⁴ emphasized the need to standardize assessment, diagnosis, and management. Additionally, the Brazilian Ministry of Health highlights that regardless of the protocol used, if breastfeeding difficulties exist, both mother and newborn must receive support within the Health Care Network²².

The Brazilian Ministry of Health also recommends training professionals to apply the protocol to standardize clinical criteria, prevent underdiagnosis, reduce overdiagnosis, and avoid iatrogenesis²². Clinical decisions must always consider breastfeeding interference, highlighting the importance of the Breastfeeding Assessment Protocol developed by UNICEF and the Ministry of Health²².

Another relevant aspect is the limitation of research on this topic due to the complexity of breastfeeding and the difficulty in evaluating outcomes of frenotomy without control groups²⁹.

Hypothesis of solution

Based on the analyses of the present study, continuing health education activities directed at dental surgeons are recommended, focusing on the diagnosis of ankyloglossia, breastfeeding assessment, and the performance of frenotomy/frenectomy in Primary Health Care in newborns and infants, with presentation of current protocols to qualify professionals and standardize clinical evaluation criteria.

Application to reality

This stage consists of the practical implementation of the proposed solution through a planned intervention aimed at transforming reality, involving planning and execution of the acquired knowledge^1,5,33.

Between October 2023 and March 2024, practical demonstrations of diagnosis and frenotomy were carried out during clinical care, according to user demand. The professionals showed openness and interest in training, and some promptly began performing the procedure in infants with a confirmed diagnosis of ankyloglossia and breastfeeding assessment after discussions and demonstrations.

In order to qualify the discussions and use the meeting as an inducer of actions², the theoretical intervention was carried out only in February 2024 to ensure the presence of all dental surgeons. The number of professionals within the unit and the limited physical structure represent a challenge for gathering all professionals at the same time.

The theoretical meeting was conducted by the facilitator for one hour and thirty minutes in an appropriate physical space—the unit auditorium—with audiovisual resources that enabled precise visualization of videos and images related to the lingual frenulum, suction patterns, breastfeeding assessment, and frenotomy/frenectomy procedures. Six dental surgeons from the Oral Health teams and one oral health technician participated in the activity.

Initially, an introduction to the topic was presented, highlighting the variable aspects of the lingual frenulum, the potential interference of ankyloglossia in breastfeeding^20,22,23, and the significant contribution of frenotomy in cases of breastfeeding difficulty^24-26.

The theoretical training addressed the topics recommended by the Brazilian Ministry of Health in Technical Note Nº 35/2018²². Visual resources were used so that all participants could observe the wide variation in anatomical aspects, as described by Martinelli et al.²⁰ and by the Ministry of Health²².

With a view to promoting breastfeeding and providing appropriate care to families and infants, the importance of the dental surgeon in Primary Health Care was highlighted, particularly in encouraging breastfeeding, diagnosis, and surgical management. One of the responsibilities of the dental surgeon in Primary Health Care is to develop educational activities to support pregnant women and their families; therefore, one of the aspects that can be addressed during prenatal care is the mandatory nature and importance of the lingual frenulum screening test in newborns^30,38.

The flow defined by the Brazilian Ministry of Health for patients with suspected ankyloglossia or with a confirmed diagnosis after protocol application, breastfeeding assessment, and the presence of breastfeeding problems was also addressed, emphasizing the role of Primary Health Care professionals after discharge from maternity services²².

Subsequently, the variety of existing protocols for characterizing ankyloglossia and the lack of consensus in the literature regarding the most appropriate diagnostic test or protocol were presented^22,23. Despite this, in Brazil there is regulation of the diagnostic protocol to be used through Technical Note Nº 35/2018.

Afterwards, the Martinelli protocol and the Bristol Tongue Assessment Tool were presented so that professionals could understand the criterion used by the Ministry of Health for choosing the protocol—ease of application. This was followed by an educational activity using the Bristol Tongue Assessment Tool, with a series of clinical cases and multiple photographs so that participants could actively evaluate different types of lingual frenulum and their characteristics, and practice score calculation.

The professionals were encouraged to reflect on low and high scores associated with breastfeeding difficulties, emphasizing that clinical conduct must always consider interference with breastfeeding, based on the Breastfeeding Assessment Protocol developed by UNICEF and the Ministry of Health²².

Subsequently, differences between the parameter used by the Federal District Health Department—the Coryllos classification (Technical Note Nº 40/2023)—and the Bristol Tongue Assessment Tool were highlighted. The four categories of the Coryllos classification are considered ankyloglossia, whereas the Bristol Tongue Assessment Tool involves evaluation of the lingual frenulum, in which, based on the score and breastfeeding assessment, the diagnosis may be negative for ankyloglossia.

The Federal District uses the Coryllos classification to define referral criteria for frenectomy in Specialized Dental Centers. Types 1 and 2 are referred to pediatric dentistry, and types 3 and 4 to periodontics. Technical Note Nº 40/2023 emphasizes that, in cases of frenotomy in newborns, the reason for not performing the procedure in Primary Health Care must be justified; therefore, ideally, this procedure should be performed within Primary Health Care, and only exceptional cases should be referred to Secondary Care.

Audiovisual materials were presented to demonstrate more precisely the technique for frenotomy in newborns and infants, as well as to address the distinction between frenectomy (complete removal of the frenulum) and frenotomy (partial incision of the frenulum), and clinical cases with follow-up of healing^35,39.

Subsequently, visual and audiovisual resources were used for breastfeeding assessment and for explaining techniques to correct improper latch, such as offering a soft breast, stimulating the infant to open the mouth, everting the lips, leaving part of the areola visible above the infant’s mouth, keeping the infant’s chin in contact with the breast, positioning the infant facing the mother, and ensuring adequate support of the infant^10,40.

The professionals actively participated throughout the meeting, asked questions, and discussed among themselves. The Bristol Tongue Assessment Tool was printed and distributed to the Oral Health teams. At the end of the theoretical session, participants were encouraged to discuss clinical cases using photographs, evaluating lingual frenulum types and practicing scoring using both the Bristol Tongue Assessment Tool and the Coryllos classification. At the end, all participants were considered capable of applying both criteria by the facilitator.

The application of the problematization methodology was effective in promoting changes in the initially observed reality. There was a clear perception of change, evidenced by the initiative of all six dental surgeons to clinically assess all infants attended or referred by Family Health teams and the multiprofessional team since the beginning of the continuing health education activities. All professionals declared themselves capable of performing the surgical procedure. After the first clinical demonstrations, two of the six dental surgeons began performing frenotomies in newborns and infants from their teams with confirmed diagnosis. The others did not present specific demand. After implementation of the Maguerez Arc, only one case was referred to Secondary Care after evaluation—a 7-year-old child with Autism Spectrum Disorder.

Final considerations

The problematization methodology was fundamental for planning actions within Primary Health Care and for qualifying dental surgeons for the management of ankyloglossia, ensuring appropriate care and encouraging breastfeeding. Problematization-based education proved effective in promoting changes in practice, stimulating critical reflection, and strengthening continuing health education. Similar strategies, with support from local management, may enhance the problem-solving capacity of Oral Health teams, consolidating a healthcare model focused on promotion, prevention, comprehensiveness, and effectiveness within Primary Health Care.

Future studies should include quantitative analyses and systematic feedback from professionals regarding training activities, as continuous evaluation is essential for the sustainability of active methodologies.

Limitations

It was not possible to quantitatively measure the number of frenotomies/frenectomies performed in the medium and long term due to the rotation of the residency program. In addition, no formal questionnaire was applied to collect feedback from professionals and patients.

Acknowledgments

The author expresses sincere gratitude to the study participants, Dr. Jéssica Alves de Cena, Maria do Carmo Silva Ribeiro, Jefferson Francisco Ribeiro, and Angelo José Morais da Silva for their continuous support.

• Ribeiro DS, Maluf F. Problem-based education for the diagnosis and management of ankyloglossia by dentists in Primary Care. Interface (Botucatu). 2026; 30: e260406 https://doi.org/10.1590/interface.260406

Data Availability

The contents underlying the research text are non-handwritten contents.

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Edited by

• Editor
  Antonio Pithon Cyrino https://orcid.org/0000-0002-9184-5927

• Editor associado
  Franklin Delano Soares Forte https://orcid.org/0000-0003-4237-0184

Publication Dates

• Publication in this collection
  31 July 2026
• Date of issue
  2026

History

• Received
  27 Mar 2025
• Accepted
  11 Mar 2026