Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_20_библиотеки_им_акад_М_И_Перельмана
.pdf
Liver Transplant
https://t.me/medicina_free
Figure 8.5.1 Facial photograph.
A. Presenting Patient
•
Four‐year‐, 11‐month‐old Caucasian male (Figure8.5.1)
B. Chief Complaint
• New patient referred by pediatric gastroenterology for
dental assessment and treatment
• Mother noted decayed teeth but no symptoms
• Mother states that teeth have always been somewhat
discolored but she is not concerned
MEdiCAlly CoMPRoMisEd PATiEnTs
• The dental professional needs to know if the
child’s liver transplant is functioning well prior
to commencing a course of dental treatment.
The liver is a complex organ with many important functions, including the synthesis of
albumin and the synthesis of blood clotting
proteins. The prothrombin time, activated
partial thromboplastin time, and international
normalized ratio are blood tests that may be
used as a guide to assess the ability of the liver
to synthesize clotting factors. Each laboratory
has its own set of reference ranges for children
of different ages
• The functioning of the liver transplant including the results of such a coagulation prole
should be discussed with the child’s physician
before commencing a course of dental treatment. Hypersplenism with sequestration of
platelets may occur in association with liver
failure but this should resolve following liver
transplantation when there should be a normal
platelet count
• It is also important to remember that live
vaccines are contraindicated in patients with
solid organ transplants because of concerns of
disseminated infection associated with immunosuppressive therapy
C. Social History
• Lives at home with six‐year‐old sibling and parents
• Middle class family
D. Medical History
• Biliary atresia, liver transplant at 13 months of age
(see Fundamental Point 1)
• Medications: tacrolimus 0.8 mg twice daily and
prednisolone 1 mg daily
• Frequent hospitalizations and hospital visits since
birth for management of biliary atresia and liver
transplant
• Allergic to eggs and nuts, no known drug allergies
Clinical Cases inPediatric Dentistry 327
t.me/Dr_Mouayyad_AlbtousH
CHAPTER 8
https://t.me/medicina_free
Some Important Functions oftheLiver
• Metabolism of carbohydrates, lipids, and proteins
• Metabolism of drugs (detoxification) prior to
excretion
• Synthesis of plasma protein (albumin) and clotting
factors
• Storage organ for glycogen, vitamin B12, and iron
• Involved in breakdown of hemoglobin; heme is
degraded to biliverdin which is converted into
bilirubin that combines with glucuronic acid to
become water soluble conjugated bilirubin that is
added to bile
Most Common Indications forPediatric Liver
Transplantation
• Chronic liver disease
Biliary atresia (most common reason for pediatric
liver transplantation)
Alpha‐1 antitrypsin deficiency
Autoimmune hepatitis
• Metabolic liver disease with extrahepatic
complications
Crigler–Najjar syndrome
Urea cycle disorders and organic acidemias
• Acute liver failure
• Hepatic tumors
A B
Figure 8.5.2 Preoperative intraoral photographs. (A) Anterior view; (B) maxillary view; (C) mandibular view.
• Vaccinations are up to date, including measles,
mumps, and rubella, which is a live vaccine that was
G. Extraoral Exam
• No significant findings
C
administered before the transplant when the patient
was immunocompetent
H. Intraoral Exam
• Soft and boney tissues: no significant findings
E. Medical Consult
Pediatric Gastroenterologist
• All tests (liver function, urea and electrolytes, blood
pressure) were within normal range for this patient
(see Background Information 1)
• Occlusal evaluation of primary dentition: class I
canines and mesial step molars
• No visible plaque
• Carious lesions on primary molars
• Greenish discoloration of teeth consistent with
history of biliary atresia (Figure8.5.2)
• Possible enamel hypomineralization and/or hypoplasia
F. Dental History
• No dental home
• Drank juices from a bottle until four years old
• Fair oral hygiene with parental supervision
of mandibular right primary second molars with
posteruptive breakdown and caries
• Erosion of palatal surfaces of maxillary anterior teeth
• Cooperative for examination and radiographs
• Uses toothpaste containing fluoride
• Optimal water fluoridation levels
• No history of dental trauma
• Asymptomatic dental caries
I. Diagnostic Tools
• Radiographs confirm extensive and deep decay involving mandibular right primary second molar (Figure8.5.3)
328 Clinical Cases inPediatric Dentistry
t.me/Dr_Mouayyad_AlbtousH
A
https://t.me/medicina_free
C
Figure 8.5.3 Preoperative radiographs. (A) Right bitewing radiograph; (B) left bitewing radiograph; (C) maxillary occlusal radiograph.
B
J. Differential Diagnosis
• Hemolytic disease of newborn
• Amelogenesis imperfecta
• Dentinogenesis imperfecta
• Coronal dentin dysplasia (Shields type II)
• Congenital porphyria
MEdiCAlly CoMPRoMisEd PATiEnTs
K.
Diagnosis andProblem List
Diagnosis
• Biliary atresia
• Early childhood caries
• Possible enamel hypomineralization and/or hypoplasia
of mandibular right primary second molars with
posteruptive breakdown and caries
• Erosion of palatal surfaces of maxillary anterior teeth
• Intrinsic staining of teeth due to incorporation of
unconjugated bile pigments in calcifying dental tissues
Problem List
• Liver transplant
• High caries risk due to:
Use of juice in a bottle until four years of age
Hospitalization as infant and young child due to
biliary atresia
Need for daily ingestion of medications
Possible enamel hypomineralization/hypoplasia of
mandibular primary second molars
Special health care needs
No dental home
Untreated caries
• Decreased metabolism (detoxication) of many
drugs including lidocaine but dental local anesthetic
agents are generally well tolerated in children with
mild to moderate liver disease: administer adequate
dose of local anesthetic to achieve profound analgesia but do not exceed the maximum recommended
dose of local anesthetic in relation to a child’s weight
Decreased metabolism (detoxication) of general
•
anesthetic and sedative agents: except for nitrous
oxide/oxygen analgesia/anxiolysis, the use of
sedation or general anesthesia should be restricted
to specialist hospital units
• Decreased production of vitamin‐K‐dependent
blood clotting factors (II, VII, IX, X): increased
potential for postextraction bleeding
• Enlargement of spleen may cause platelet sequestration with associated low platelet count: increased
potential for postextraction bleeding
•
Local measures to control postextraction bleeding
include the use of oxidized regenerated cellulose
(Surgicel or Gelfoam) and the use of resorbable sutures
• Hematology consult if platelet count <50 000/mm3
and/or if abnormalities in coagulation prole
Varices (enlarged blood vessels) at base of esopha-
•
gus due to obstruction of blood ow to diseased
liver: chronic gastrointestinal hemorrhage may
result in anemia
• Greenish discoloration of teeth due to incorporation of bile pigments during period of calcication
of teeth
• Do not use nonsteroidal anti‐inammatory drugs
(NSAIDs), such as aspirin or ibuprofen, for analgesia because they increase the risk of gastrointestinal bleeding
• Prescribe acetaminophen for analgesia with caution, adhering to recommended therapeutic dosages–hepatotoxicity is dose‐related so avoid high
doses in children with liver impairment
Clinical Cases inPediatric Dentistry 329
t.me/Dr_Mouayyad_AlbtousH
CHAPTER 8
https://t.me/medicina_free
• Immunosuppressant therapy to prevent rejection of
liver transplant
• Significant dental treatment required in a four‐year‐
old with history of extensive medical intervention
since birth
L. Comprehensive Treatment Plan
• Establishment of a caries prevention plan as well as a
dental home
• Comprehensive dental treatment under general
anesthesia (see Fundamental Point 2)
Intravenous administration of hydrocortisone
25 mg at time of induction because of long‐term
steroid use
• Stainless steel crown restoration of mandibular
rightprimary second molars following caries
removal
• High‐strength glass ionomer or composite resin
restorations of occlusal lesions in both maxillary
primary second molars and mandibular primary first
molars
• Postoperative pain relief with acetaminophen 500 mg
as a suppository and intraoral buccal infiltration of
0.5 ml 2% lidocaine with epinephrine
Follow‐up Care
• Postoperative and home care instructions
• Establishment of a frequent recall schedule
M. Prognosis andDiscussion
• Good prognosis if the following aggressive preventive
plan is established and consistent home and professional dental care is provided:
Three‐month dental recall visits
Fluoride varnish application at each recall visit
Fissure sealant application to the permanent first
molars when erupted sufficiently to allow isolation
for moisture control
Promotion of twice daily toothbrushing with fluoride
toothpaste
Restriction in the frequency of ingestion of sugary
drinks/juices and sugary snack foods
N. Common Complications andAlternative
Treatment Plans
• Extensively decayed mandibular right second primary
molar:
Vital pulpotomy and stainless steel crown if pulp
exposure
Extraction of tooth if nonvital with infection and
subsequent space management/maintenance when
permanent first molar erupts
• Distal shoe appliance relatively contraindicated in
view of immunosuppression
• Long‐term complications of steroid and immunosuppression agents with dental implications: gingival
overgrowth, high blood pressure, osteoporosis
330 Clinical Cases inPediatric Dentistry
t.me/Dr_Mouayyad_AlbtousH
• Caries prevention: educate child and caretakers on
https://t.me/medicina_free
the importance of optimal oral care at time of
transplantation and afterwards
• Treat/stabilize active dental decay so that the teeth
will not be a potential source of infection at the
time of transplantation and for the following three
to six months
• Extract extensively decayed teeth and teeth with
pulp or potential pulp pathology
• Consult the pediatric gastroenterology team:
seek advice on coagulation status and ensure a
platelet count of >50 000/mm3 before extracting teeth
• Regular dental visits for preventive and ongoing
care following transplant
• Be aware of potential immunosuppression issues
• Scrupulous crossinfection control measures
• Decreased immunosurveillance
MEdiCAlly CoMPRoMisEd PATiEnTs
Increased risk of lymphomas (non‐Hodgkin
lymphomas or post‐transplant lymphoproliferative disease)
Increased risk of skin cancer: reinforce safety in
sun and the use of sunscreen with high sun
protection factor
• Cyclosporine with or without the antihypertensive
drug nifedipine may cause gingival hyperplasia and
delayed eruption of teeth
• Consider tacrolimus as an alternative to cyclosporine as it does not typically induce gingival
hyperplasia
• Caution with use of NSAIDs for analgesia because
these may increase the nephrotoxicity of cyclosporine and tacrolimus
• Glucocorticoids may be used in low dosage as
immunosuppressant: additional dosage not usually
required for dental treatment unless treatment
provided under general anesthesia
• Azathioprine and mycophenolate mofetil are other
immunosuppressant drugs that may be used
following solid organ transplantation. They have no
signicant oral or dental side effects
Self‐Study Questions
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 331
t.me/Dr_Mouayyad_AlbtousH
CHAPTER 8
https://t.me/medicina_free
Self‐Study Answers
period of calcification of teeth
adhering to recommended therapeutic dosages–
hepatotoxicity of acetominophen is dose‐related so
avoid high doses in children with liver impairment
in a child with a liver transplant because they may
increase the nephrotoxicity of the immunosuppressant drugs, cyclosporine and tacrolimus
Bibliography andAdditional Reading
American Academy of Pediatric Dentistry. 2018–2019. Use of
local anesthesia for pediatric dental patients. In: Clinical
Practice Guidelines and Best Practices (Reference Manual).
Pediatr Dent 40:274–80. https://www.aapd.org/research/
oral‐health‐policies‐‐recommendations/use‐of‐local‐
anesthesia‐for‐pediatric‐dental‐patients
Cocero N, Bezzi M, Martini S etal. 2017. Oral surgical treat-
ment of patients with chronic liver disease: assessments
of bleeding and its relationship with thrombocytopenia
andblood coagulation parameters. J Oral Maxillofac Surg
75:28–34.
Golla K, Epstein JB, Cabay RJ. 2004. Liver disease: current per-
spectives on medical and dental treatment. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 98:516–21.
Greenwood M, Meechan JG. 2003. General medicine and sur-
gery for dental practitioners; Part 5: liver disease. Br Dent J
195:71–3.
Guggenheimer J, Eghtesad B, Stock DB. 2003. Dental manage-
ment of the (solid) organ transplant patient. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 95:383–9.
Kuhnisch J, Daublander M, Klingberg G etal. 2017. Best clinical
practice guidance for local analgesia in paediatric dentistry: an
EAPD policy document. Eur Arch Paediatr Dent 18:313–21.
Schör K. 2007. Aspirin and Reye’s syndrome–a review of the
evidence. Pediatr Drugs 9:195–204.
Scully C. 2014. Scully’s Medical Problems in Dentistry, 7th
Edition. Edinburgh: Elsevier.
Seow WK, Shepherd RW, Ong TH. 1991. Oral changes associated
with end‐stage liver disease and liver transplantation: implications for dental management. J Dent Child 58:474–80.
Sheehy EC, Heaton N, Smith P, Roberts GJ. 1999. Dental man-
agement of children undergoing liver transplantation. Pediatr
Dent 21:273–81.
Wondimu B, Nemeth A, Modeer T. 2001. Oral health in liver
transplant children administered cyclosporine A or tacrolimus. Intern J Paediatr Dent 11:424–9.
332 Clinical Cases inPediatric Dentistry
t.me/Dr_Mouayyad_AlbtousH
Type 1 Diabetes
AC
https://t.me/medicina_free
B
E
MEdiCAlly CoMPRoMisEd PATiEnTs
C. Social History
• Cared for by his mother
• Attends preschool in the mornings
• Father is an information technology employee who has
moved to the country to undertake a Master’s degree
• Two younger siblings
• Family recently immigrated for his father to pursue his
training
D. Medical History
• Type 1 diabetes (see Background Information 1)
• No known drug allergies
D
• Medications: insulin injections
• Hospitalization at time of diagnosis of diabetes (at age
two years)
• Emergency room visit related to initial presentation of
diabetes
• No previous surgery
Figure 8.6.1 (A–E) Preoperative intraoral photographs showing
multiple severe carious lesions.
A. Presenting Patient
• Four‐year‐old male
• African origin
B. Chief Complaint andHistory ofPresent
Illness
• Referred from community dental care provider for
assessment and management of severe dental
disease with pain symptoms including night wakening, and history of “dental abscess”
• Presented today with his mother who speaks basic
English
t.me/Dr_Mouayyad_AlbtousH
E. Medical Consult
• Consult with pediatrician to determine:
Medications
HbA1C levels
Suitability for ambulatory care general anesthesia
Sickle cell investigations
F. Dental History
• History of night time ad lib breastfeeding until age
three
• Ongoing requirement for sugar‐containing foods
between meals to manage his blood glucose levels
• Tooth brushing began at age three; now brushes once
daily (in the morning) unsupervised
• Uses a fluoridated toothpaste
• Resides in a community with fluoridated water supply
• No dental trauma history
• Cooperative for clinical examination but unable to
cooperate for intraoral radiographs
Clinical Cases inPediatric Dentistry 333
CHAPTER 8
https://t.me/medicina_free
• Type 1 diabetes (insulin‐dependent diabetes mellitus) is
an autoimmune condition occurring when a person’s
pancreatic beta cells are destroyed and the body stops
making insulin. Insulin is required for glucose to pass
from the bloodstream into the cells and regulate the
body’s blood glucose level. Over time, hyperglycemia
leads to damage to many body systems, particularly
the vascular and nervous systems. If not well
controlled, diabetes can cause vision loss, renal failure,
and lead to lower limb amputation and other
consequences that impact signicantly on quality of life
• There is wide global variation in incidence and
prevalence, from 0.5 to 60 new cases per 100 000
children aged under 15 years. Onset of type 1
diabetes is usually rapid, and symptoms include:
increased excretion of urine (polyuria), increased
thirst (polydipsia), constant hunger, weight loss,
vision changes, and fatigue
• Early diagnosis is possible with inexpensive testing
of blood sugar
• Normal fasting blood glucose level in a healthy individual
should be 4.0–7.0 mmol/l. Random plasma glucose
testing is useful in diagnosis of type 1 diabetes, when
time is of the essence. Arandom plasma glucose level
of 11.1 mmol/L or more, or a fasting level of 7.0 mmol/l or
more, is indicative of diabetes. The glycosylated
hemoglobin (HbA1C or A1C) test is a measure of blood
glucose control over the preceding two to three
months. It measures glycosylation of hemoglobin. The
American Diabetes Association suggests an A1C of 7%
or above is considered diabetes
• People with type 1 diabetes monitor blood glucose
several times per day and constantly and carefully
balance their diet, exercise, and other activities
with their insulin intake to maintain appropriate
blood glucose levels. Insulin is administered
usually by injection or by a pump. There are several
types of insulin in use: rapid‐acting, short‐acting,
intermediate‐ acting, long‐acting, and pre‐mixed.
Each patient will have a tailored insulin regime that
is specific to his/her situation
• Has received care from the community dentist only in
an emergency situation to manage pain and infection
• No ongoing dental home
• No previous attempts at dental treatment in community
G. Extraoral exam
• Weight and height are age‐appropriate
• Right‐sided submandibular lymphadenopathy
H. Intraoral exam
•
Soft tissue: localized swelling adjacent to primary
mandibular right and left second molars; generalized
marginal gingivitis secondary to plaque accumulation
• Dentition: developmentally appropriate dentition
• Occlusion: mesial step; normal incisor relationship
• Dental exam (Figure8.6.1):
Proximal, occlusal, and smooth surface demineralization and extensive cavitation
Multiple unrestorable teeth and high‐risk caries
pattern including carious mandibular incisors
Pulp polyp in primary maxillary left second molar
I. Diagnostic Tools
A B
C
E
D
therefore intraoral radiographs were obtained at time
of general anesthesia) (Figure8.6.2):
334 Clinical Cases inPediatric Dentistry
Figure 8.6.2 (A–E) Preoperative radiographs showing multiple
severe carious lesions, furcation radiolucencies, and pathological external root resorption.
t.me/Dr_Mouayyad_AlbtousH
MEdiCAlly CoMPRoMisEd PATiEnTs
https://t.me/medicina_free
Gross breakdown with only root remnants remaining of primary maxillary left first molar
Furcation radiolucencies associated with primary
maxillary right first molar, primary mandibular left
second molar, and primary mandibular right second
molar
Pathological external inflammatory root resorption
noted for primary maxillary right first molar and
primary mandibular right second molar
Carious pulpal involvement of all primary molars
Carious maxillary incisors but with normal apical
tissues
Possibly hypoplastic development of permanent
mandibular right second premolar related to extensive infection of primary predecessor
• Even with careful monitoring and a strict regime,
many people with type 1 diabetes can have blood
glucose levels which are difficult to control. This can
lead to dangerously high (hyperglycemia) or low
(hypoglycemia) blood sugar levels. In extreme
cases, this can be life‐threatening
• Causes of hypoglycemia include:
Excess insulin
Exercise
Delayed/skipped meal
Excess oral hypoglycemics
Alcohol consumption
Stress
• When blood glucose falls to <4 mmol/l, a “hypo” is
experienced. Mild hypoglycemia symptoms include:
sweating, dizziness, trembling, tingling (hands, feet,
lips, and tongue), blurred vision, difficulty
concentrating/tiredness, and hunger. Moderate
hypoglycemia signs include: odd behavior, rudeness/
spontaneous laughter, appearing drunk, bad‐
tempered, aggressive or confused, uncooperative
and refusing to treat low blood sugar. Severe
hypoglycemia results in loss of consciousness.
• Treatment of hypoglycemia is best performed early,
and if carried out appropriately, should be effective
within two to four minutes. As the patient becomes
more irritable and confused, administration of
glucose may become more difficult. Glucose intake
can be in the form of a sugary drink (juice/soda), a
• Laboratory values: HbA1C, blood glucose level on
admission for surgery
J. Differential Diagnosis
• Hypomineralized second primary molars possibly a
contributory factor, but pattern of breakdown is
consistent with diagnosis of severe early childhood
caries caused by ad lib breastfeeding
K. Diagnosis andProblem List
Diagnosis
• Severe early childhood caries complicated by localized
odontogenic infection on a background of type 1
diabetes
glucose lozenge/candy, as a prepackaged gel, or even
in the form of squeezable cake icing. Once the initial
recovery is established, a more complex form of
carbohydrate (bread, biscuit, banana) should be given
• Prolonged hyperglycemia results in diabetic ketoacidosis. This is a serious emergency associated with
significant morbidity and mortality. If suspected of
having ketoacidosis, the patient should be advised
to contact the diabetic team immediately. Diabetic
ketoacidosis tends to develop over a long period of
time, and may be caused by:
Illness/infection (including a dental infection which
can cause a serious increase in blood sugar)
Inadequate insulin
Stress
Hormonal changes (pregnancy/menstruation,
testosterone, and growth hormone)
Steroid therapy
• Symptoms include:
Thirst (this can be extreme)
Tiredness/lethargy/drowsiness
Xerostomia
Excessive urination (with high urine glucose
levels)
Reduced resistance to infection
• The treatment for diabetic ketoacidosis is fast‐acting insulin by a trained provider. A diagnosis of
ketoacidosis must be absolutely certain: there can
be catastrophic results of incorrectly administering
insulin to a patient with hypoglycemia
Clinical Cases inPediatric Dentistry 335
t.me/Dr_Mouayyad_AlbtousH
CHAPTER 8
https://t.me/medicina_free
Problem List
• Pain
• Chronic infection in immune compromised host with
high risk for spreading infection
• Risk for poor diabetic control due to presence of
infection
• Limited language skills of mother, who is the primary
caregiver
• Limited parental understanding of link between oral
health and systemic health
• Poor oral hygiene practices and feeding practices
• Poor cooperation
• Potential risk for hypoglycemia due to prolonged
fasting for general anesthesia or reduction of oral
intake postoperatively (see Background Information 2)
L. Comprehensive Treatment Plan
• Engage the services of a professional translator to
ensure advice, education, risks, benefits, and treatment
options can be adequately understood by the mother. If
possible, invite the father to also attend appointments
• Enable parents to seek urgent treatment of spreading
infection should it develop, by educating them on
signs (fever, swelling, malaise) and establishing either
the hospital service or the community service as the
provider for this care if needed. Treat spreading
infection aggressively with high dose antibiotics
• Clarify the dental home provider
• Create a caries preventive plan:
Commence twice daily supervised brushing with
fluoridated (>1000 ppm) toothpaste
Application of 22 500 ppm fluoride varnish to entire
dentition every three months
Ensure that sweetened foods are given only as
indicated by blood glucose requirements and not as
discretionary foods
Using a motivational interviewing approach, educate
parents regarding the oral health risks of night time
ad lib breastfeeding
• Urgent comprehensive restorative and surgical care
under general anesthesia in collaboration with medical colleagues, if possible, to minimize the need for
repeat general anesthesia (see Fundamental Point 1)
• Follow‐up care:
Soft diet for up to 48 hours
Acetaminophen for 48 hours +/‐ ibuprofen for
48hours if needed
Toothbrushing to recommence after 24 hours
Recall plan: at three months and plan follow‐up care
with dental home provider
• Consider orthodontic evaluation to address space loss
concerns once caries disease process is managed.
Space maintenance is neither indicated nor feasible at
this point
M. Prognosis andDiscussion
• Prognosis for treatment of infection is good, in that
removal of the source of the infection (i.e. the
resolution of infection without the need for
systemic antibiotic therapy
• Prognosis for carious teeth treated with full coronal
coverage is good due to high success rate of preformed metal crowns.
• Prognosis for good oral health is guarded since
diabetes can predispose the patient to xerostomia,
thus elevating caries risk, and can result in delayed
wound healing and oral candidiasis
• Prognosis for limiting caries disease progression is
guarded due to limited parental understanding of the
impact of dietary and oral hygiene practices on oral
health and disease. This is complicated by the language barrier and the social isolation experienced by
the child’s mother living in a foreign country, caring for
small children
N. Common Complications andAlternative
Treatment Plans
• Consider attempting emergency extraction with
nitrous oxide sedation if child is adequately cooperative using this technique
• Caries control: if comprehensive care under general
anesthesia cannot be provided soon, apply silver
diamine fluoride to teeth with active caries but
without pulpal involvement
In severely decayed teeth consider extraction versus
•
indirect pulp therapy/pulpotomy and crown
• Although not common in children, individuals with
diabetes are more susceptible to periodontal
disease, and poor periodontal health may affect
blood glucose control. Individuals with diabetes
should be encouraged to practice meticulous
home oral care, and to see their dental professional very regularly
336 Clinical Cases inPediatric Dentistry
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана