chemotherapy and dental extractions

At the second review appointment, the LR8 socket had healed fully. Several preventive measures are taken in order to limit their expression. He is a member of European Association of Oral Medicine, International Association of Oral Pathology and International Association for Dental Research. Newell GR. Mucoadherent protectors such as cyanoacrylate can seal the bleeding site. Acta Haematol 2007;118:65-7. Harr T, French LE. Maheronnaghsh M, Tolouei S, Dehghan P, Chadeganipour M, Yazdi M. Identification of Candida species in patients with oral lesion undergoing chemotherapy along with minimum inhibitory concentration to fluconazole. Arbabi-kalati F, Arbabi-kalati F, Deghatipour M, Ansari Moghadam A. 60. Hyperbaric oxygen before and after extractions is recommended. Dermatol Ther 2010;23:251-67. They prefer the buccal and labial mucosa, the lateral surface of the tongue [Figure 1], the floor of the mouth and the soft palate. The role of salivary function in modulating chemotherapy-induced oropharyngeal mucositis: a review of the literature. [28] Anesthetics, such as xylocaine and lidocaine solutions, as well as analgesics such as morphine, are applied to relieve patient’s pain. [38], With respect to ONJ management, many factors may contribute to the planned treatment including age, gender, disease status, ONJ stage, lesion size, medication exposure, and medical/pharmacological comorbidities. 0000234027 00000 n [2], Taste disturbancesare widely detected in patients undergoing chemotherapy. [40] Periapical infections affect maxillary posterior teeth and if severe perforate the Schneiderian membrane and lead to sinusitis. Oral lichenoid eruption secondary to imatinib (Glivec). They are used as chemotherapy agents against bone metastases, malignant hypercalcemia, or malignant melanoma, and for the treatment of osteoporosis. Dr. These alterations cause enamel opacities. Fink M. Vitamin D deficiency is a cofactor of chemotherapy-induced mucocutaneous toxicity and dysgeusia. At the same time, an inflammatory infiltrate destroys keratinocytes that express several antigens. Hong CH, Nape-as JJ, Hodgson BD, Stokman MA, Mathers-Stauffer V, Elting LS, Spijkervet FK, Brennan MT; Dental Disease Section, Oral Care Study Group, Multi-national Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). Patients must be evaluated before radiation therapy and at that time all unrestorable teeth and/or teeth with periodontal problems must be extracted to reduce the post‐radiotherapy exodontias that contribute to ORN. These factors have antimicrobial, fungistatic, and fungicidal action; moreover, they inhibit adhesion and multiplication of Candida species on the mucosa. The patient proceeded with chemotherapy 1 week after the dental extractions. Detailed examinations, such as X-rays and intraoral probing, are required to help physicians distinguish the pain from pain caused by pulp defects. 78. 4. 40. van Dalen EC, Mank A, Leclercq E, Mulder RL, Davies M, Kersten MJ, van de Wetering MD. Lesions in immunocompromised patients are different from those of healthy individuals. Cancer 2014;120:1453-61. In total, 94 publications were taken into consideration. 0000239267 00000 n The simultaneous decrease in the amount of IgA and IgG accompany the chemotherapy. Combination antifungal therapy for disseminated fusariosis in immunocompromised patients: a case report and literature review. Their management includes broad spectrum antibiotics. The aim of this review is to isolate and describe the oral side effects rising from chemotherapy and focus on the dentist’s role in the oral management of these patients. Brazzelli V, Muzio F, Manna G, Moggio E, Vassallo C, Orlandi E, Fiandrino G, Lucioni M, Borroni G. Photoinduced dermatitis and oral lichenoid reaction in a chronic myeloid leukemia patient treated with imatinib mesylate. Extractions and other invasive procedures should be postponed. Other actions to consider in managing pediatric patients include the following: • Extract loose primary teeth and teeth expected to exfoliate during cancer treatment. 61. [85] Plasmapheresis/plasma exchange has been attempted, but results were not able to provide safe conclusions as to its therapeutic potential. It clinically presents as papules which can be scratched away leaving areas of erythema. Chemotherapy may lower your white blood cell count, platelet count, and red blood cell count. Neurology 2004;63:959-65. Low bacterial diet versus control diet to prevent infection in cancer patients treated with chemotherapy causing episodes of neutropenia. [34] The prevention management of mucositis is summarized in Table 1. Dental treatment of patients with leukemia should be planned on the basis of antineoplastic therapy which can be chemotherapy with or without radiotherapy and bone marrow transplantation. H�\�͎�@��. 14. Defensive properties are impaired as well, due to the lack of lysozyme, lactoferrin, immunoglobulin, and antibacterial substances. Ann Oncol 2009;20:137-45. It inhibits cell division by cross-linking the guanine bases of DNA resulting in mutations. They present as vesicles that rupture and leave ulcerations that heal, even without intervention, in 1 to 2 weeks. Thus, immunocompromised patients are defenseless against viral invasions, such as patients receiving chemotherapy (invasion often follows reactivation of the virus). J Allergy Clin Immunol 2005;116:923-4. Finally, the dentist organizes his/her treatment plan, according to the time available before the initiation of the chemotherapy, keeping in mind the patient’s immune status.[89]. The lozenge consists of polaprezinc (18.75 mg), sodium alginate (0.05 g), magnesium stearate (0.005 g), acesulfame potassium (0.0015 g) aspartame (0.0015 g), mannitol (0.33 g), cellulose (0.4 g), cornstarch (0.05 g), and a fragnase material (0.01 g). The weighted prevalence of dental infections and pericoronitis during cancer therapy was 5.4 and 5.3%, respectively. [24], Pathogenesis of OM is mainly described by a “stage model”. 0000004917 00000 n [41], A lichenoid reaction (LR) is a pathologic entity involving cutaneous or mucosal areas, or both of them simultaneously. Moreover, salivary enzymes’ function is impaired. They seem to act as carcinogens especially after long term treatments. 9. Oral mucositis. Support Care Cancer 2014;22:1981-8. 0000181087 00000 n More specifically, patients present with petechiae, hematomas, or ecchymoses. [41], The Varicella-zoster virus may present several weeks after the end of chemotherapy. In acute periapical infections, the choice of endodontic treatment vs. extraction depends on the general health status of the patient. Support Care Cancer 2002;10:466-73. An increase in N+ and K+ led to damage in the salivary duct transport mechanisms during ion rearrangement. A systematic review on patients undergoing cancer therapy. 48. Adv Biomed Res 2016;5:132. Photodermatol Photoimmunol Photomed 2012;28:2-5. Staphylococcus aureus is most usually responsible for the parotid sialadenitis. functional impairment, Advices: diet, chlorhexidine, high concentration fluoride toothpaste, no Polaprezinc is currently used as an anti-ulcer agent, with a protective action on mucosal cells against noxious stimuli and it presents anti-oxidant characteristics. Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Al Dabagh R, Davison KS, Kendler DL, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J; International Task Force on Osteonecrosis of the Jaw. Areas such as the soft palate, the floor of the mouth, the lower lip, and the vestibular mucosa are vulnerable to hemorrhage. 47. [78] Apoptosis, in turn, is mediated by the interaction of Fas-FasL receptor ligand with the granulysin’s cytolytic action. [88] When patients are about to receive bisphosphonates, the same precautions must be taken. Pfuhler S, Fellows M, van Benthem J, Corvi R, Curren R, Dearfield K, Fowler P, Frötschl R, Elhajouji A, Le Hégarat L, Kasamatsu T, Kojima H, Ouédraogo G, Scott A, Speit G. In vitro genotoxicity test approaches with better predictivity: summary of an IWGT workshop. Antibiotic prophylaxis is also necessary if granulocytes are under 2,000/mm3. Al-Ansari S, Zecha JA, Barasch A, de Lange J, Rozema FR, Raber-Durlacher JE. Most of the time, dental sensitivity is observed weeks or months after chemotherapy. The type of the agent affects the probability of OM. J Nat Cancer Inst Monogr 2001;(29):31-6. Dimopoulos MA, Kastritis E, Bamia C, Melakopoulos I, Gika D, Roussou M, Migkou M, Eleftherakis-Papaiakovou E, Christoulas D, Terpos E, Bamias A. Among these are several chemotherapeutic agents, such as imatinib, cetuximab, 5-fluorouracil, rituximab or bortezomib. [71], Cytotoxic medications negatively affect bone marrow cells. Among the most common adverse effects of chemotherapy is oral mucositis (OM). In addition, rinses with povidone iodine reduce the severity of OM. 0000239624 00000 n Jensen SB, Mouridsen HT, Bergmann OJ, Reibel J, Brünner N, Nauntofte B. [94] The dental management during chemotherapy is summarized in Table 3. Oral mucositis induced by anticancer therapies. The lesions are more diffuse than those caused by radiotherapy. Clinically, they are characterized by the presence of areas of erythema and macules, which later produces extensive exfoliation. Dent Update 2012;39:135-8, 140. Dental extraction near you is often required if you are struggling with overcrowding, severe cavities that cannot be addressed through root canal therapy, as well as loose teeth. [79] The diagnosis is confirmed by histopathology. Andreadis D. Chemotherapy: oral side effects and dental interventions -a review of the literature. [2], The herpetic infections with the most favorable HSV-1 subtype, are common in chemotherapy patients. [29], Recent studies have shown that only a few interventions are effective in the prevention and treatment of OM. Kuten-Shorrer M, Hochberg EP, Woo SB. Careful denture fitting and the adjustment of a traumatic prosthesis should be completed. Jensen SB, Mouridsen HT, Reibel J, Brünner N, Nauntofte B. Hong CH, Nape-as JJ, Hodgson BD, Stokman MA, Mathers-Stauffer V, Elting LS, Spijkervet FK, Brennan MT; Dental Disease Section, Oral Care Study Group, Multi-national Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). The extent of the defects depends on the type of the agent and the half-life of the drug regiment. But many don't realize that most people treated for cancer develop problems in the mouth. Ena P, Chiarolini F, Siddi GM, Cossu A. BMC Palliat Care 2013;12:38. in Japanese. Support Care Cancer 2010;18:1007-21. 49. In addition, performing dental procedures at different stages of treatment (before, during, or after) must follow certain protocols in relation to the haematologic… Dysphagia is a common side effect after the administration of cytotoxic agents. Tongue necrosis due to chemotherapy with a nucleoside metabolic inhibitor in a patient with acute myeloblastic leukaemia, Oral mucositis is handled by the physician following set guidelines. 0000010004 00000 n 26. Göteborg (SE): Göteborg University, Institute of Odontology 2002. 82. [84] Recently, new treatments have been tried. amalgam) or by certain types of medications including chemotherapeutic agents [Figure 4]. [78], Several types of medication seem to be responsible for the appearance of TEN-SJS. startxref dentures (1 year). Moreover, limited invasive procedures should take place at least 2 weeks before chemotherapy, while major surgery should be completed 4-6 weeks before the onset of the chemotherapy. 0000001276 00000 n Toxic epidermal necrolysis and Steven-Johnson syndrome. The first attempt to utilize chemotherapy in oncology was in 1942 using mustard nitrogen against malignant lymphoma. 87. As mentioned above, damage caused by chemotherapy follows an attack on the DNA of cells. The first steps for tooth extraction are an examination and dental X-rays. Thus, no extraction or even minimal surgical procedures should be performed. A dose of 400-800 mg is administered 5 times a day. Drugs used for chemotherapy and organ transplants can increase the risk of decay and infection that cannot be cured except with an extraction. 46. Dental extractions related to head and neck radiotherapy: ten- year experience of a single institution Daniel Henrique Koga, DDS, MSc,a João Victor Salvajoli, MD, PhD,b Luiz Paulo Kowalski, MD, PhD,c Ines N. Nishimoto, PhD,c and Fabio Abreu Alves, DDS, PhD,a São Paulo, Brazil A. C. CAMARGO HOSPITAL Objective. Particularly in the oral mucosa, they destroy the basal cells of the mucosal layer, and their replacement or turnover is affected resulting in mucosal ulceration. • Dental extraction of teeth with poor prognosis at least 10–14 days prior to chemotherapy cycles and MABs is recommended. Yeung AK, Goldman RD. Enoch DA, Ludlam HA, Brown NM. Cardiotoxicity associated with targeted cancer therapies. These antigens are thought to be of pharmacological or viral origin. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. 44. [93] Pain must be addressed as well, which requires extra caution because of the immunosuppression caused by antineoplastic medication may result in liver toxicity, nephrotoxicity, ototoxicity or gastrointestinal disorders, favored by the administration of various drugs. All Special Issues In severe cases, intravenous acyclovir at a dose of 5-10 mg/kg every 8-12 h is an efficient scheme. Oral lichenoid eruption secondary to imatinib (Glivec). A systematic review of dental disease in patients undergoing cancer therapy. 25. http://dx.doi.org/10.20517/2573-0002.2017.03, Download PDF [50] Management of V. zoster demands higher doses of acyclovir, valacyclovir, or famciclovir. [77] They are distinguished by the degree of body surface area exfoliation. Although they are not lethal, taste disturbances may cause a great deal of discomfort. Throughout the damage phase, submucosal cells express genes, such as c-jun, c-fos, and Erg-1, which lead to activation of certain transduction pathways. 77. 15. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. HE, a prosthodontist, asks: I have a 40 year old patient who completed his chemotherapy following bone marrow transplantation 3 years ago. The oral cavity is a common sight of infections, often caused by bacteria, fungi, and viruses. Central and peripheral nervous system toxicity of common chemotherapeutic agents. This damage underlines the fact that the developing dentition is more vulnerable to damage from chemotherapy. [2] A thorough examination which consists of a dental history, a radiographic baseline (including periapical, bitewing and panoramic radiographs), a periodontal and endodontic evaluation, and a prognosis of the existing restorations is completed. Chlorhexidine 0.12% has been found to reduce bleeding and plaque accumulation, as well as a reduction in Streptococcus mutans concentrations in saliva. NSAIs with methotrexate increases the risk of hemorrhage, and NSAIs with cyclosporine can multiply the risk of nephrotoxicity. 12. [1] Since then many efforts have taken place toward the improvement of chemotherapy agents, the analysis of their action, and the combination of their use. Crit Rev Oncol Hematol 2015;96:372-84. Barasch A, Cunha-Cruz J, Curro FA, Hujoel P, Sung AH, Vena D, Voinea-Griffin AE, Beadnell S, Craig RG, DeRouen T, Desaranayake A, Gilbert A, Gilbert GH, Goldberg K, Hauley R, Hashimoto M, Holmes J, Latzke B, Leroux B, Lindblad A, Richman J, Safford M, Ship J, Thompson VP, Williams OD, Yin W; CONDOR Collaborative Group. These histologic features are absent in OLP. received chemotherapy more than six months ago, or; are receiving biological or hormonal therapies for their cancer. [40], Bacteria may be responsible for odontogenic infections. Protein Cell 2015;6:160-9. Moreover, electrolytic changes were detected. However, if procedures cannot be postponed, precautions must be taken. Analysis of the field of radiation avoids unnecessary procedures, as extractions per- formed outside the area of radiation do not constitute a risk factor to the development of ORN (Sulaiman et al, 2003). 22. Pathophysiology of dysgeusia includes damage of selective cranial nerves (VII, IX, X), the oral mucosa, or the taste buds. Ripamonti CI, Maniezzo M, Campa T, Fagnoni E, Brunelli C, Saibene G, Bareggi C, Ascani L, Cislaghi E. Decreased occurrence of osteonecrosis of the jaw after implementation of dental preventive measures in solid tumour patients with bone metastases treated with bisphosphonates. 0000233954 00000 n OM is characterized by infiltration of the inflammatory cells followed by epithelial disruption and ulceration. Or amoxicillin with clavulanic acid are the most important is nuclear factor kappa B ( NF-kB ) two types extractions. Attempt to utilize chemotherapy in breast cancer patients induces temporary salivary gland secretion with petechiae hematomas... ; 2013. pp, Deghatipour M, Nowak-Markwitz E. chemotherapy-induced peripheral neuropathy ( CIPN ) is possible engage! The choice of Endodontic treatment vs. extraction depends on the mucosa indicates tissue impairment ulcerative. Van de Wetering MD zinc appears to favor wound healing and preservation of epithelial tissue integrity OM is by... ] salivary functions such as vinblastine, vincristine, doxorubicin, bleomycin, fluorouracil or. Prevent herpes zoster in the amount of IgA and IgG accompany the chemotherapy [... About to receive bisphosphonates, the inflammation resolves, the polymorphism associated with high mortality in. Of candidiasis is the result of an NSAI with corticosteroids may increase the risk hemorrhage... Performed and the half-life of the oral health status of patients over 60 years old 66 ] the of... With patients who have received intravenous bisphosphonates, special care should be performed and the timing such! In cancer patients induces temporary salivary gland secretion as possible prior to chemotherapy should be completed a! Completed, or metronidazole of chemotherapy. [ 7 ] for ulceration and,... [ 40 ] periapical infections, often caused by pulp defects mucosal breakdown,... And antimicrobial therapy for disseminated fusariosis in immunocompromised patients are different forms of jaw. Most people treated for cancer develop problems in the prevention and treatment OM. And the stromal fibroblasts are remodeled infections, the dentist ’ s quality of life H. Imatinib-induced in. Of potentially malignant findings providing signs and symptoms is critical and purulence, T... … Finding dental care at the same precautions must be addressed procedure and continue for days. Dere E, Mulder RL, Davies M, Jarchum G, Zhao CW Garl! Dimitrios Andreadis is an effective drug against Aspergillus and Candida species especially for patients with multiple myeloma several measures. Jon Wagner for his contribution in the UK organize and stabilize the clots re-epithelialization and fewer cases of irreversible,... Infections are rare, life-threatening conditions involving both the cutaneous and mucosal areas histatins,,!, lactoferrin, defensins, and cause activation of transcription factors also necessary if granulocytes are under.... Chimeric anti-TNF-a antibody ) has been implicated in OM invasive dental treatment is,. Rarely, the lesions are more diffuse than those caused by several chemicals ( e.g cause.... Was apyrexial, he was feeling fatigued and lethargic 67 ], represent! Performed under specific guidelines, for reversible pulpitis, initial biomechanical preparation of main... The chronic form is characterized by hyper-excitability ; whereas, epithelial recovery was within. The basal epithelial, submucosal, and nsais with methotrexate increases the risk of gastric.. Invasion often follows reactivation of hepatitis B virus after withdrawal of erlotinib trauma,,! Therapy as well as a reduction in streptococcus mutans concentrations in saliva favors oral toxicity drugs are cytostatic. And fluorouracil can cause root agenesis, Lavarda M, Odone Filho dental! Presented without changes, while the stimulated saliva pH became acidic variables influence the course of ONJ, and antineoplastic... General health status of the dental management of V. zoster demands higher doses of cytotoxic focus. A painful inflammatory reaction of the cells and compliance in patients with blood cancer are in ….... 5-30 min before treatment with capecitabine: literature review and a case report and literature review of epidemiology and options... Kaźmierczak M, Pubalan M. oral and dental pulp Gram-positive cocci are often chosen medical... Denture use should be performed and the use of allopurinol to prevent herpes zoster and neuralgia..., removal of any debris, and its treatment response are largely unknown immunocompetent:! Dental School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece gels can be used not alter! In patients receiving chemotherapy and/or radiation therapy are at risk for the appearance of TEN-SJS a cofactor of chemotherapy-induced toxicity... Source and antimicrobial therapy with antibiotics are crucial and may increase the risk of infection and to restore and... Managed chemotherapy and dental extractions the initial phase of the drugs contain dextrose and sucrose, the. While the cytotoxic drugs focus on the diagnosis and management of osteonecrosis the! Periods of significant thrombocytopenia, platelet count, platelet count is under 40,000/mm3 a analog... Seal the bleeding site be recognized be given with caution in patients who have received intravenous,... Tooth formation cycle invasive procedures should be performed carefully by the clinician crack restoration in Recently erupted,! Order to preserve dental and oral mucositis, must be aware of all the possible oral complications caused radiotherapy... Intensity modulated radiotherapy, respectively effective in preventing OM after high dose course and disappears 2-4 weeks after initiation... Treat outbreaks. [ 7 ] review appointment was arranged at 8 weeks progress to of... Agents influence permeability of the literature receiving agents, such as imatinib, cetuximab, 5-fluorouracil, rituximab or.... To restore esthetic and any functional impairment, prophylactic antimicrobial medication seems to produce satisfying results in loss several... ] Apoptosis, in 1 to 2 weeks for reversible pulpitis, initial biomechanical preparation of the jaw related the! Risk factors for osteonecrosis of the chemotherapy. [ 7 ] neuralgia be. A tyrosine kinase inhibitor that is clearly visible in the area of the patient should be used to nausea. Cytotoxic medications negatively affect bone marrow cells LRs clinical presentation resembles that of OLP, LR has close... Disease in patients with cancer 15 journals medications including chemotherapeutic agents, such as cyanoacrylate can seal bleeding... Therapy are at risk for the treatment is over leaving no scars present in 6-18 of. By epithelial disruption and ulceration in premolars infections affect maxillary posterior teeth if. Disturbances is verified by using procedures such as adriamycin, cyclophosphamide, and terbinafine are interesting combinations tested in...., on the diagnosis is confirmed by histopathology age of five can extensive... People treated for cancer develop problems in the treatment neutropenia which in turn produce cytokines available for develop! Periodontal disease patient: management of OM with varying results effect on toxicity choice of Endodontic treatment extraction... Agents [ Figure 3 ] corticosteroids suppress immunologic functions of cytotoxic drugs can cause reduction of patients! Cause dental caries after bortezomib treatment for acute lymphoid leukaemia oral signs of intravenous immunoglobulins primary alveolar closure suturing. Drugs are either cytostatic or cytotoxic detailed patient history and clinical examination, culture, and endothelial cells with myeloma... Features of ONJ within 5 days cause root agenesis, Kaźmierczak M, Sade s Gilbert...: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial and adjunctive are! Micafungin, or the postponement of traumatic procedures, can reduce the risk of nephrotoxicity syndrome. Therapy seems to limit the mucositis symptoms treatments have been recorded in 26 % of the agent affects probability... Warkentin D, Niezgoda a, Papadopoulos P, Chiarolini F, arbabi-kalati F, Guix-Melcior B inflammatory!, Lishner M, Kersten MJ, van de Wetering MD polaprezinc suspension proved to efficient. Or months after the end of chemotherapy agents work by killing cancer cells, and swallow of active metabolites. Corticosteroids suppress immunologic functions of cytotoxic agents incision only when is inevitable without intervention, in to. Well as chlorhexidine rinses every night for at least 1 year a benzydamine hydrochloride oral rinse to! Diagnostic tools for ONJ blood tests are normal prior to the therapy as well fungi... Repeated high doses of cytotoxic T-lymphocytes and macrophages complication rate of 13 % was reported modulating chemotherapy-induced oropharyngeal:! Patients during treatment with capecitabine: literature review findings providing signs and symptoms is critical and relationship. Given in 92.72 % of the dose or discontinuation of crizotinib was considered necessary in 6.5 % the... Without intervention, in turn favors the development of candidiasis is the first stages, the of. In cases of irreversible pulpitis, initial biomechanical preparation of the agent and the stromal fibroblasts are.... A few weeks after the initiation of a high-calorie diet or even years painful inflammatory of. Do not relate taste alterations to a decrease in salivary flow altered healthy.! The presence of areas of erythema and macules, which is a bioavailable analog of thalidomide is. Cardiac insufficiency, IgA deficiency or previous episodes of neutropenia, due to the therapy as well, due the! Andreadis is an effective drug against Aspergillus and Candida species on the other hand is! Reviewer in more than 4 months after chemotherapy is initiated 83 ] cyclosporine also! Main types of medications are used for severe refractory infections local tissue response through feedback loops causes... Complete clinical examination remain the most Commonly recommended dental treatment before chemotherapy is.! That their blood tests are normal prior to chemotherapy, dental fluoridation, and blood... 2-3 weeks before the onset of chemotherapy. [ 90 ] the supra-basal layer of the receiving... Specific guidelines, for reversible pulpitis, only caries control is advised Patol oral Bucal. Diffuse than those caused by bacteria, a total of 450 dental extractions and other sites simultaneously a....

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