Overuse of Antibiotic Prophylaxis in Dentistry: What the Evidence Really Says

The overuse of antibiotic prophylaxis in dentistry has become a significant concern due to its contribution to antimicrobial resistance, adverse drug reactions, and unnecessary healthcare costs.

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While prophylactic antibiotics can be life-saving in select high-risk patients, mounting evidence shows that they are frequently prescribed without clear indications, especially for routine dental procedures. This article reviews what current scientific evidence and clinical guidelines truly recommend, helping clinicians make safer, more rational decisions.

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✅ Understanding Antibiotic Prophylaxis in Dentistry
Antibiotic prophylaxis refers to the preventive administration of antibiotics before dental procedures to reduce the risk of bacteremia-related systemic infections, most notably infective endocarditis (IE). Historically, broad indications led to widespread use. However, modern guidelines have dramatically narrowed eligible patient groups.

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✅ Why Is Antibiotic Prophylaxis Overused?
Several factors drive overprescription:

▪️ Outdated clinical training and reliance on obsolete protocols
▪️ Defensive dentistry driven by fear of legal consequences
▪️ Patient expectations and misconceptions
▪️ Misinterpretation of transient bacteremia, which also occurs during daily activities like tooth brushing
Evidence shows that routine dental procedures rarely cause clinically significant bacteremia beyond normal daily exposure.

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✅ What Does Current Evidence Say?
High-quality studies and guideline updates consistently demonstrate that:

▪️ Only a small subset of patients benefit from prophylaxis
▪️ There is no convincing evidence that routine prophylaxis prevents infective endocarditis in low-risk individuals
▪️ The harms often outweigh benefits in most dental patients
Organizations such as the American Heart Association (AHA) and American Dental Association (ADA) now recommend prophylaxis only for patients at highest risk of adverse outcomes.

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✅ Risks Associated with Overuse
The inappropriate use of antibiotics is not benign. Documented risks include:

▪️ Antibiotic resistance, a global public health threat
▪️ Adverse drug reactions, including anaphylaxis
▪️ Clostridioides difficile infection, particularly with clindamycin
▪️ Disruption of the oral and gut microbiome

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✅ Who Actually Needs Antibiotic Prophylaxis?
According to current evidence-based guidelines, prophylaxis is limited to patients with:

▪️ Prosthetic cardiac valves or prosthetic material for valve repair
▪️ Previous infective endocarditis
▪️ Certain congenital heart diseases (unrepaired cyanotic CHD, repaired CHD with residual defects)
▪️ Cardiac transplant recipients with valvulopathy
For most dental patients, including those with orthopedic implants or controlled systemic diseases, prophylaxis is not indicated.

📊 Comparative Table: Antibiotic Prophylaxis in Dentistry – Evidence-Based Perspective

Aspect	Advantages	Limitations
Targeted use in high-risk patients	Reduces risk of severe systemic complications	Applies to a very limited patient population
Routine use in low-risk patients	No proven clinical benefit	Increases antimicrobial resistance and adverse effects
Guideline-based prescribing	Improves patient safety and antibiotic stewardship	Requires continuous clinician education
Patient reassurance without antibiotics	Encourages preventive oral hygiene and trust	May conflict with patient expectations

💬 Discussion
The paradigm has shifted from routine prevention to selective protection. Evidence confirms that daily oral activities produce bacteremia comparable to dental procedures, rendering indiscriminate antibiotic use ineffective. Dentists play a crucial role in antibiotic stewardship, aligning clinical decisions with scientific evidence rather than tradition or fear.

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🎯 Clinical Recommendations
▪️ Strictly follow AHA and ADA guidelines
▪️ Avoid prescribing antibiotics for routine extractions, restorations, or orthodontic procedures in low-risk patients
▪️ Emphasize oral hygiene and regular dental care as primary preventive measures
▪️ Educate patients about the real risks of unnecessary antibiotics
▪️ Document medical risk assessment clearly in the clinical record

✍️ Conclusion
The overuse of antibiotic prophylaxis in dentistry is not supported by current evidence and poses significant risks to both individual patients and public health. Restricting prophylaxis to clearly defined high-risk groups, guided by updated clinical recommendations, is essential for safe, ethical, and evidence-based dental practice.

📚 References

✔ American Heart Association. (2021). Prevention of Viridans Group Streptococcal Infective Endocarditis. Circulation, 143(20), e963–e978. https://doi.org/10.1161/CIR.0000000000000969
✔ American Dental Association. (2023). Antibiotic Prophylaxis Prior to Dental Procedures. Journal of the American Dental Association, 154(2), 110–118. https://doi.org/10.1016/j.adaj.2022.10.006
✔ Lockhart, P. B., Tampi, M. P., Abt, E., et al. (2019). Evidence-based clinical practice guideline on antibiotic use for the urgent management of dental pain and intraoral swelling. JADA, 150(11), 906–921. https://doi.org/10.1016/j.adaj.2019.08.020
✔ Wilson, W., Taubert, K. A., Gewitz, M., et al. (2007). Prevention of infective endocarditis. Circulation, 116(15), 1736–1754. https://doi.org/10.1161/CIRCULATIONAHA.106.183095

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When Is Antibiotic Prophylaxis Indicated in Pediatric Dentistry?

Antibiotic prophylaxis in pediatric dentistry remains a highly specific and restricted clinical practice.

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Its primary objective is to prevent systemic infections caused by transient bacteremia during invasive dental procedures in children with underlying medical conditions. Current recommendations emphasize judicious use to reduce antimicrobial resistance and adverse effects.

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✅ When Is Antibiotic Prophylaxis Indicated in Children?
According to updated guidelines from the American Heart Association (AHA) and American Dental Association (ADA), antibiotic prophylaxis is recommended only for pediatric patients at highest risk of serious systemic complications.

1. Cardiac Conditions Requiring Prophylaxis
Antibiotic prophylaxis is indicated in children with:

▪️ Previous history of infective endocarditis
▪️ Prosthetic cardiac valves or prosthetic material used for valve repair
▪️ Certain congenital heart diseases, including:
- Unrepaired cyanotic congenital heart disease
- Repaired congenital heart disease with residual defects
▪️ Cardiac transplant recipients who develop valvulopathy

Routine cardiac murmurs or fully repaired congenital defects do not require prophylaxis.

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2. Dental Procedures That Require Prophylaxis
Prophylaxis is recommended only when procedures involve manipulation of gingival tissue, the periapical region, or perforation of oral mucosa, such as:

▪️ Tooth extractions
▪️ Periodontal procedures
▪️ Placement of orthodontic bands (not brackets)
▪️ Endodontic treatment beyond the apex

Local anesthetic injections through non-infected tissue, radiographs, and placement of removable appliances do not require prophylaxis.

📊 Comparative Table: Antibiotic Prophylaxis in Pediatric Dental Patients

Aspect	Advantages	Limitations
Prevention of Infective Endocarditis	Reduces risk of life-threatening cardiac infection	Indicated only in high-risk pediatric patients
Evidence-Based Prescription	Aligns with international clinical guidelines	Requires thorough medical history and diagnosis
Single-Dose Regimen	Minimizes antibiotic exposure	Incorrect timing reduces effectiveness
Antimicrobial Stewardship	Prevents unnecessary antibiotic use	May be misunderstood by caregivers

💬 Discussion
Scientific evidence indicates that most cases of infective endocarditis are not directly linked to dental procedures, but rather to daily activities such as chewing or toothbrushing. This understanding has led to narrower indications for antibiotic prophylaxis. Overprescription offers no additional benefit and increases risks such as antibiotic resistance and allergic reactions, particularly in children.

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🎯 Clinical Recommendations
▪️ Prescribe antibiotic prophylaxis only for children with clearly defined high-risk conditions
▪️ Perform a detailed medical history review before invasive procedures
▪️ Follow current AHA and ADA guidelines strictly
▪️ Educate parents about why prophylaxis is not routinely indicated
▪️ Emphasize optimal oral hygiene to reduce bacteremia from daily activities

✍️ Conclusion
Antibiotic prophylaxis in pediatric dentistry should be limited to well-defined, high-risk cases. Adhering to evidence-based guidelines protects vulnerable patients while promoting responsible antibiotic use. Proper diagnosis, clear communication, and preventive oral care remain the most effective strategies for safeguarding pediatric systemic health.

📚 References

✔ Wilson, W., Taubert, K. A., Gewitz, M., et al. (2007). Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation, 116(15), 1736–1754. https://doi.org/10.1161/CIRCULATIONAHA.106.183095
✔ Nishimura, R. A., Otto, C. M., Bonow, R. O., et al. (2017). 2017 AHA/ACC focused update on valvular heart disease. Circulation, 135(25), e1159–e1195. https://doi.org/10.1161/CIR.0000000000000503
✔ American Dental Association. (2021). Antibiotic prophylaxis prior to dental procedures. Journal of the American Dental Association, 152(8), 647–654.
✔ Lockhart, P. B., Brennan, M. T., Thornhill, M., et al. (2009). Poor oral hygiene as a risk factor for infective endocarditis–related bacteremia. Journal of the American Dental Association, 140(10), 1238–1244. https://doi.org/10.14219/jada.archive.2009.0046

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Antibiotics in Pediatric Dentistry: When They Are Needed and When They Are Not

The rational use of antibiotics in pediatric dentistry is essential to prevent antimicrobial resistance, reduce adverse events, and ensure safe, effective care. Current guidelines from the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) emphasize that most dental infections in children can be managed without antibiotics when local treatment is possible.

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This guide reviews indications, contraindications, dosing considerations, and clinical decision-making for antibiotics in pediatric patients, with updated evidence-based recommendations.

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✅ When Antibiotics Are Indicated in Pediatric Dentistry
Antibiotics should only be prescribed when there is systemic involvement, risk of dissemination, or when dental treatment alone is insufficient.

1. Odontogenic Infections With Systemic Symptoms
Antibiotics are indicated when infections present with:
▪️ Fever >38°C
▪️ Facial swelling or cellulitis
▪️ Lymphadenopathy
▪️ Difficulty swallowing (dysphagia) or trismus
▪️ Risk of airway compromise

Common first-line options:
▪️ Amoxicillin
▪️ Amoxicillin–clavulanate (Augmentin®)
▪️ Clindamycin for penicillin-allergic patients

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2. Acute Facial Cellulitis of Dental Origin
Requires:
▪️ Systemic antibiotics
▪️ Drainage when indicated
▪️ Close clinical follow-up

3. Traumatic Dental Injuries With Pulp Exposure + High Infection Risk
Situations such as:
▪️ Luxation injuries with contamination
▪️ Avulsion of permanent teeth
Recommended:
▪️ Amoxicillin or doxycycline (for children ≥8 years)

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4. Patients With Specific Medical Conditions
Antibiotic coverage is recommended for:
▪️ Immunocompromised children
▪️ Children with certain cardiac conditions requiring endocarditis prophylaxis following AHA guidelines
Only specific procedures (manipulation of gingival tissue, apical region, or perforation of oral mucosa) warrant prophylaxis.

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✅ When Antibiotics Are Not Indicated in Pediatric Dentistry
AAPD and ADA emphasize several cases where antibiotics offer no clinical benefit:

1. Localized Dental Infections Without Systemic Involvement
Examples:
▪️ Localized pulpitis
▪️ Localized periapical abscess without fever or swelling
▪️ Periodontal abscess confined to the gingiva

These are best managed with:
▪️ Pulp therapy
▪️ Drainage
▪️ Restorative care
▪️ Analgesics

2. Irreversible Pulpitis or Symptomatic Pulpitis
Antibiotics do not reduce pain or improve outcomes.

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3. Routine Dental Procedures
Including:
▪️ Extractions without complications
▪️ Pulpotomies
▪️ Restorations

4. Viral Infections
Herpetic gingivostomatitis and other viral lesions do not respond to antibiotics.

💬 Discussion
The overprescription of antibiotics in children significantly contributes to drug-resistant bacteria, allergic reactions, and gastrointestinal disturbances. Evidence demonstrates that local dental treatment is the most effective therapy for the majority of pediatric infections, while antibiotics serve only as adjunctive therapy in specific systemic conditions.
Adherence to AAPD and ADA guidelines ensures:
▪️ Lower risk of antimicrobial resistance
▪️ Reduced emergency visits
▪️ Improved patient outcomes
Providers must carefully evaluate whether systemic involvement is present before prescribing antibiotics, especially in younger children, where unnecessary exposure increases risks.

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🔎 Clinical Recommendations
▪️ Prioritize definitive dental treatment (pulp therapy, extraction, incision and drainage) whenever possible.
▪️ Prescribe antibiotics only when systemic involvement or facial cellulitis is present.
▪️ Choose amoxicillin as the first-line agent; use clindamycin for penicillin-allergic patients.
▪️ Avoid antibiotics for pulpitis, localized abscess, or routine procedures.
▪️ Follow weight-based pediatric dosing strictly:
° Amoxicillin: 20–40 mg/kg/day divided every 8 hours
° Amoxicillin–clavulanate: 25–45 mg/kg/day divided every 12 hours
° Clindamycin: 10–25 mg/kg/day divided every 8 hours
▪️ Educate parents on correct administration and the importance of completing the course.
▪️ Reassess cases within 24–48 hours when antibiotics are prescribed.

✍️ Conclusion
Antibiotics are not routinely needed in pediatric dentistry, and local treatment is sufficient in most cases. Their use should be reserved for systemic infection, facial cellulitis, medically complex patients, or situations where dental treatment cannot be immediately performed. Adopting evidence-based prescribing practices reduces antimicrobial resistance and ensures high-quality pediatric dental care.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Use of antibiotic therapy for pediatric dental patients. https://www.aapd.org
✔ American Dental Association. (2023). Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. https://www.ada.org
✔ Wilson, W., Taubert, K. A., Gewitz, M., et al. (2021). Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation, 143(8), e963–e978. https://doi.org/10.1161/CIR.0000000000000969
✔ Thikkurissy, S., Rawlins, J. T., Kumar, A., Evans, E., & Casamassimo, P. S. (2019). Influenza-like illness in a dental setting: A survey of antibiotic use for pediatric patients. Pediatric Dentistry, 41(1), 45–50.
✔ AAPD. (2022). Guideline on Management of Acute Dental Trauma. https://www.aapd.org

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Antibiotic Prophylaxis in Pediatric Dentistry: Updated Guide for Safe Antibiotic Selection

Antibiotic prophylaxis (AP) in pediatric dentistry is indicated only in high-risk patients for infective endocarditis (IE) or specific systemic conditions, before dental procedures that involve gingival tissue, the periapical region, or oral mucosa perforation.

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The first-line regimen is amoxicillin, while clindamycin is no longer recommended due to its adverse effect profile. The dose must be administered 30–60 minutes before the procedure (up to 2 hours after if forgotten).

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✅ Indications: Which children need antibiotic prophylaxis?
AP is reasonable in pediatric patients with high-risk cardiac conditions undergoing invasive dental procedures:

° Prosthetic cardiac valves or prosthetic material for valve repair.
° Previous history of IE.
° Certain congenital heart diseases: unrepaired cyanotic CHD, CHD repaired with prosthetic material (first 6 months), or repaired CHD with residual defects.
° Cardiac transplant with valvulopathy.

AP is not recommended for other congenital heart conditions, for non-invasive dental procedures, or routinely for prosthetic joints.

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✅ Dental procedures requiring AP

° Yes: procedures involving gingival manipulation, periapical region, or oral mucosa perforation.
° No: anesthesia in non-infected tissue, dental radiographs, orthodontic appliance placement/adjustment, shedding of primary teeth, trauma to lips/mucosa.

✅ Pediatric antibiotic regimens (single dose, 30–60 min before procedure)

Scenario	Antibiotic (Route)	Pediatric Dose	Max Dose	Timing	PK/PD Notes
First-line regimen	Amoxicillin (PO)	50 mg/kg	2 g	30–60 min before	β-lactam; time-dependent (T>MIC). Renal elimination.
Unable to take PO	Ampicillin (IM/IV)	50 mg/kg	—	30–60 min before	β-lactam; T>MIC. Renal elimination.
Unable to take PO	Cefazolin or Ceftriaxone (IM/IV)	50 mg/kg	—	30–60 min before	Cephalosporins; T>MIC. Avoid in penicillin anaphylaxis.
Penicillin/ampicillin allergy (non-anaphylaxis)	Cephalexin (PO)	50 mg/kg	—	30–60 min before	Safe only if no history of anaphylaxis/angioedema.
Penicillin/ampicillin allergy	Azithromycin or Clarithromycin (PO)	15 mg/kg	Azithro: 500 mg	30–60 min before	Macrolides; AUC/MIC. Clarithro: CYP3A4 interactions.
Penicillin allergy (alternative)	Doxycycline (PO)	<45 kg: 2.2 mg/kg; ≥45 kg: 100 mg	—	30–60 min before	Tetracycline; short use usually safe in children.

Note: Clindamycin is no longer recommended for AP in dental patients.

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✅ Pharmacodynamics and pharmacokinetics

° β-lactams (amoxicillin, ampicillin, cephalosporins): bactericidal, time-dependent (T>MIC). Short half-life, renal elimination.
° Macrolides (azithromycin, clarithromycin): concentration-time dependent (AUC/MIC); azithromycin has a long half-life, clarithromycin is metabolized via CYP3A4.
° Doxycycline: broad distribution, concentration-dependent; short-course use does not cause permanent tooth staining.

✅ Practical considerations and stewardship

° Avoid clindamycin due to C. difficile risk.
° Avoid cephalosporins if prior anaphylaxis to penicillin.
° Do not prescribe AP for routine dental care or orthodontics.
° Delay elective procedures if the patient is already on antibiotics.
° Promote antibiotic stewardship: limit use, educate parents, and prioritize oral hygiene.

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💬 Discussion
Evidence shows that AP prevents very few cases of IE, while maintaining good oral hygiene and controlling plaque reduce bacteremia more effectively. Current guidelines restrict AP to high-risk children undergoing invasive dental procedures. This approach reduces unnecessary antibiotic exposure and the risk of adverse effects.

✍️ Conclusion
Antibiotic prophylaxis in pediatric dentistry is not routine. It is indicated only for children with high cardiac risk undergoing invasive dental procedures. Amoxicillin 50 mg/kg (max 2 g) remains the first-line drug. Alternatives include oral cephalosporins, macrolides, or doxycycline (selected cases), with clindamycin excluded. Integration of antibiotic stewardship principles and collaboration with pediatricians and cardiologists is essential.

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📚 References (APA)

✔ American Academy of Pediatric Dentistry (AAPD). (2024). Use of antibiotic therapy for pediatric dental patients (Best Practices). Chicago, IL: AAPD. https://www.aapd.org/globalassets/media/policies_guidelines/bp_antibiotictherapy.pdf
✔ American Academy of Pediatric Dentistry (AAPD). (2021, rev. 2023). Antibiotic prophylaxis for dental patients at risk for infection (Best Practices). Chicago, IL: AAPD. https://www.aapd.org/globalassets/media/policies_guidelines/bp_antibioticprophylaxis.pdf
✔ American Dental Association (ADA). (2022). Antibiotic prophylaxis prior to dental procedures. https://www.ada.org/resources/ada-library/oral-health-topics/antibiotic-prophylaxis
✔ American Dental Association (ADA). (2023). Antibiotic stewardship. https://www.ada.org/resources/ada-library/oral-health-topics/antibiotic-stewardship
✔ Wilson, W. R., Gewitz, M., Lockhart, P. B., Bolger, A. F., DeSimone, D. C., Kazi, D. S., ... & Baddour, L. M. (2021). Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation, 143(20), e963–e978. https://doi.org/10.1161/CIR.0000000000000969

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Antibiotic Prophylaxis in Pediatric Dentistry: When and How to Use It Safely in 2025

Antibiotic prophylaxis in pediatric dentistry is a preventive measure used to avoid serious systemic infections, such as infective endocarditis, in children undergoing dental procedures.

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The practice is guided by evidence-based protocols from organizations such as the American Heart Association (AHA) and the American Academy of Pediatric Dentistry (AAPD). Its use must be justified, as improper administration increases the risk of adverse effects and antibiotic resistance.

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✅ What Is Antibiotic Prophylaxis in Pediatric Dentistry?
This involves the preventive administration of antibiotics before invasive dental procedures in children who are at high risk for systemic infections. The aim is to minimize transient bacteremia that could colonize vulnerable tissues, such as the heart valves, particularly in immunocompromised or medically complex pediatric patients.

✅ Mechanism of Action
Antibiotics used for prophylaxis work by eliminating or reducing oral bacteria that can enter the bloodstream during dental procedures. The antibiotic is given 30–60 minutes before treatment to achieve optimal blood levels.

° Amoxicillin inhibits bacterial cell wall synthesis (bactericidal).
° Clindamycin inhibits bacterial protein synthesis (bacteriostatic or bactericidal depending on concentration).
° Macrolides (azithromycin, clarithromycin) also inhibit protein synthesis and are used in penicillin-allergic patients.

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✅ Clinical Indications

1. High-Risk Cardiac Conditions (Per AHA Guidelines)
Antibiotic prophylaxis is recommended for children with:
° Prosthetic heart valves or materials
° History of infective endocarditis
° Certain congenital heart defects (unrepaired, recently repaired with residual defects, or cyanotic CHD)
° Cardiac transplant recipients with valve disease

2. Immunocompromised Patients
Including those with:
° Cancer undergoing chemotherapy
° Neutropenia
° Organ transplants
° Long-term corticosteroid therapy
° IV bisphosphonate therapy

3. High-Risk Dental Procedures
Prophylaxis is recommended only for invasive procedures such as:
° Tooth extractions
° Periodontal surgery
° Deep scaling and root planing
° Any procedure causing mucosal or gingival bleeding

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✅ Recommended Antibiotics and Pediatric Dosing

💬 Discussion
Current research and AHA/AAPD guidelines stress that antibiotic prophylaxis should only be used when clinically indicated. Studies have shown that eliminating routine prophylaxis in low-risk patients did not increase the incidence of infective endocarditis. Misuse or overuse contributes to antibiotic resistance, Clostridioides difficile infection, and other complications.
Dentists must evaluate each child’s medical history and assess whether the risk justifies prophylactic use. Furthermore, educating caregivers on the responsible use of antibiotics is essential to support safe dental practices.

💡 Conclusion
Antibiotic prophylaxis in pediatric dentistry is a valuable tool for preventing severe infections but should be limited to patients with specific high-risk conditions. Updated guidelines from the AHA and AAPD emphasize evidence-based decision-making and individual risk assessment. Dental professionals must stay informed and adhere to standardized protocols to ensure the best outcomes for pediatric patients.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Use of antibiotic therapy for pediatric dental patients. The Reference Manual of Pediatric Dentistry, 533–537.

✔ Wilson, W. R., Gewitz, M., Lockhart, P. B., et al. (2021). Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation, 143(20), e963–e978. https://doi.org/10.1161/CIR.0000000000000969

✔ Suda, K. J., Calip, G. S., Zhou, J., et al. (2019). Assessment of the appropriateness of antibiotic prescriptions before dental procedures. JAMA Network Open, 2(5), e193909. https://doi.org/10.1001/jamanetworkopen.2019.3909

✔ Hollingshead, C. M., & Brizuela, M. (2023). Antibiotic prophylaxis in dental and oral surgery practice. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470357/

✔ Zovko Končić, M., & Ivanušić, I. (2024). Antibiotic prophylaxis in dentistry: Recommendations and guidelines. Dentistry Journal, 12(11), 364. https://doi.org/10.3390/dj12110364

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Update on antibiotic prophylaxis in pediatric patients

Antibiotic prophylaxis aims to prevent the presence of a new infection from a therapeutic procedure. This preventive action is more important if the patient is immunocompromised.

In pediatric dentistry or general dentistry, the general health status of the child must be known, as well as his or her history and the severity of the infection, in order to determine the correct administration of antibiotics.

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We share an article that explains the importance of antibiotic prophylaxis, and the pharmacological management that we must consider in common dental procedures.

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Antibiotics and its use in pediatric dentistry: A review

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Planells-del Pozo P, Barra-Soto MJ, Santa Eulalia-Troisfontaines E. Antibiotic prophylaxis in pediatric odontology. An update. Med Oral Patol Oral Cir Bucal 2006;11:E352-7. © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946

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