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Case ReportThe Case for Improved Interprofessional Care: Fatal AnalgesicOverdose Secondary to Acute Dental Pain during Pregnancy
Sarah K. Y. Lee,1 Rocio B. Quinonez,2 Alice Chuang,3
Stephanie M. Munz,4 and Darya Dabiri4
1Department of Prosthodontics, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA2Department of Pediatric Dentistry and Pediatrics, Schools of Dentistry and Medicine, University of North Carolina at Chapel Hill,Chapel Hill, NC, USA3Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA4Department of Oral and Maxillofacial Surgery/Hospital Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
Correspondence should be addressed to Sarah K. Y. Lee; sarah lee@unc.edu
Received 28 April 2016; Accepted 28 September 2016
Academic Editor: Asja Celebic
Copyright © 2016 Sarah K. Y. Lee et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. Thiscase report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose formanagement of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverseoutcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death frommultiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognizeand optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative andcoordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overallquality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessionaleducation and practice are necessary to enhance the quality of care that will benefit all patients.
1. Introduction
The pregnant dental patient exemplifies the need for collabo-rative practices between health disciplines.The latest nationalconsensus statement regarding oral healthcare during preg-nancy indicates patients can and should undergo routinedental treatment during all stages of pregnancy as “oral healthcare, including use of radiographs, pain medication, andlocal anesthesia, is safe throughout pregnancy” [1]. Whiletreatment rendered during the second trimester provides thegreatest comfort, pregnancy alone is not a contraindication toreceiving dental treatment [1]. For some women, pregnancymay in fact provide the opportunity to pursue their oralhealthcare needs [2, 3]. For example, some states’ govern-ment assistance programs include dental care as a coveredpregnancy-related service [4]. In 2000, the Children’s HealthInsurance Program extended coverage to include pregnantwomen who do not qualify for Medicaid [3].
Despite these progressive efforts to provide prenatal oralhealthcare, inconsistencies between the knowledge and prac-tices of dental and medical providers regarding prenatal oralhealthcare remain. Pregnant patients continue to encounterbarriers that may adversely affect their oral health andnegatively impact their pregnancy [1–11]. This case reportdescribes a sequence of events, precipitated by dental pain, inwhich lapses in patient oral health literacy, the rendering ofdental treatment, and coordination of interprofessional col-laborative treatmentwithin the healthcare system culminatedin the demise of both the fetus and pregnant patient.
2. Case Presentation
A 19-year-old at 17-week gestation presented to her localhospital’s emergency department (ED) complaining ofabdominal pain and nausea. She was diagnosed with acute
Hindawi Publishing CorporationCase Reports in DentistryVolume 2016, Article ID 7467262, 8 pageshttp://dx.doi.org/10.1155/2016/7467262
2 Case Reports in Dentistry
liver failure secondary to acetaminophen overdose for dentalpain management. The admission record indicated, as perpatient report, that she had received dental treatment 2weeks earlier, with the dentist reportedly prescribing 20tablets of Tylenol #3 (acetaminophen with codeine) forpostoperative pain. The patient initially took 1-2 tablets perday, but due to persisting symptoms, she communicatedwith her obstetrician who recommended over-the-counterTylenol for pain management. The patient obtained ExtraStrength Tylenol (500mg acetaminophen/tablet) andfor a 10-day period reported taking 2-3 tablets of ExtraStrength Tylenol, 10 times per day, approximating 20–30tablets daily or 10,000–15,000mg daily. Preliminary EDlaboratory studies indicated acute liver injury consisting ofcoagulopathy and abnormal transaminases with significantlyelevated acetaminophen levels. To address the liver toxicity,N-acetylcysteine (NAC) protocol was initiated at the localED and continued when the patient was transferred to alarger academic center’s pediatric intensive care unit (ICU)(Table 1).
When transferred, a consultation with obstetrics andgynecology (ObGyn) was completed. A live singleton fetushad been initially confirmed by ultrasound; however, onreevaluation on her second day of hospitalization, no fetalcardiac activity was detected and fetal demise was diagnosed.The following day, a dental consultation was initiated due tothe patient’s complaint of pain on mastication of the rightmandibular dentition. Clinical and radiographic examinationinitially revealed no emergent dental needs, and occlusaladjustments to alleviate symptomswere performed as the firstcourse of action (Figure 1).
While undergoing care the patient was diagnosed withWilson’s disease, an autosomal recessive genetic disordercausing copper accumulation in tissues that can lead tofurther liver complications [12]. Her laboratory findingsconfirmed the abnormally elevated copper levels, which inaddition to her acute liver injury from toxicity resulted in therecommendation for liver transplant. On day 9 of hospital-ization, the delivery of the nonviable fetus was completed,and the patient’s condition was reported as stable. At thistime, a second dental consultation was ordered following thepatient’s report of a “bubble on [the] gum that popped.”
The dental assessment revealed that tooth #30 (perma-nent right mandibular first molar) had a draining sinus tract.Two days following the diagnosis, prophylactic antibioticmanagement was initiated and a pulpectomy was scheduledand completed in the hospital’s dental clinic under localanesthesia. On the scheduled treatment date, the patientreported not feeling well as she had not ingested solid food orsubstantial liquids for more than 12 hours, due to her nil peros (NPO) status as ordered by her medical care team. Whilethis action resulted in delay of treatment, the pulpectomywas completed without complication that same afternoon.At this time, the dental team overseeing the patient’s carediscussed the previously rendered treatmentwith the patient’sgeneral dentist via telephone. The following dental treatmenthad been reportedly completed in a single appointment bythe general dentist and was documented in the patient’selectronic record: dental restorations on 7 teeth (#12, 13, 16,
Figure 1: Panoramic radiograph of the patient’s dental condition onday 15 of first hospitalization.
17, 19, 20, and 21), 3 root canal therapies (#14, 15, and 18),and placement of 2 stainless steel crowns. Further requestswere made to the dentist to share treatment records with thehospital dentistry team. To date, these records have not beenreceived.
Dental clearance evaluation and any necessary treatmentin preparation for a liver transplant were requested by thepatient’s medical team. The following treatment was thenrecommended: endodontic therapy of pulpal necrosis withsinus tract of tooth #30, extraction of tooth #14 (permanentleft maxillary molar) due to nonrestorability, and extractionof maxillary and mandibular third molars (teeth #1, 16, 17,and 32) due to impaction causing operculi and periodontalcomplications.The patient was subsequently discharged fromthe hospital with plans to address dental treatment needs andmanagement of liver failure by the respective care teams onan outpatient basis.
One week after discharge, the patient was readmitted tothe ED for pelvic pain that had been worsening for 3 days.She disclosed, as documented on her electronic record, a lackof compliance with the prescribed medication regimen “asshe does not know what these medications do.” Treatmentfor spontaneous bacterial peritonitis (SBP) was initiated bythe gastroenterology (GE) team but was discontinued after2 days due to lack of correlation of signs and symptomsobserved from laboratory studies and patient history. Duringthis stay, a dental follow-up evaluation was completed. Thepatient reported being asymptomatic for any oral pain and,upon clinical examination, the draining sinus tract adjacentto tooth #30 had resolved. No emergent needs were evident.The patient was discharged after a 4-day hospitalization.
Three days after her second hospitalization, the patientpresented to the dental outpatient clinic for completion ofendodontic therapy for tooth #30 and consultation with theoral andmaxillofacial surgery (OMFS) service for extractionsof third molars and tooth #14 under general anesthesia.Endodontic therapy was completed in the dental clinicwithout complication and the patient was scheduled toreturn to complete other indicated restorative treatments.The extractions were completed in the operating room undergeneral anesthesia by the OMFS service the same weekwithout complications.
Case Reports in Dentistry 3
Table1:Summaryof
thep
atient’scourse
ofillness.
Date
Event
2weeks
before
hospita
lization
Patie
ntob
tainsd
entalcare.Her
dentalprovider
prescribed
20tabs
ofTy
leno
l3forp
ainmanagem
ent.Patie
nttakes1-2
tabs/day
butp
ain
persists.Sh
econ
tactsh
erob
stetricianwho
advisesO
TCacetam
inop
henforp
ainmanagem
ent.Patie
ntob
tainsE
xtra
Streng
thTy
leno
l(500
mgacetam
inop
hen/tab)
andtakes2
-3tabs,10tim
es/day
forlast10days
(20–
30tabs/day).
Firsth
ospitalization
Day
1Patie
ntpresentsto
localemergencydepartment(ED
)for
abdo
minalpain
andnausea.D
iagn
osisof
acuteliver
injury
isassessed.
N-Acetylcysteine(NAC
)treatmentisinitia
ted.
Day
2Patie
nttransfe
rred
topediatric
ICUandliver
managem
entcon
tinuedviaN
ACprotocol.O
bstetricsa
ndgynecology
(ObG
yn)team
identifi
eslives
ingleton
fetusv
iaultrasou
nd.
Day
3Und
etectablefetalheartsou
ndso
rfetalmovem
entb
yObG
yn.Fetaldemise
diagno
sisismade.
Day
4Patie
ntrepo
rtsp
ainon
mastic
ationof
right
poste
riord
entition.
Hospitald
entistry(H
D)con
sultisrequ
estedby
patie
nt’scare
team
.
Day
5HDconsultatio
ncompleted.C
linicalexam
inationrevealsn
oindicatio
nfore
mergent
interventio
nald
entaltreatment.Palliativetreatmentis
rend
ered
viao
cclusaladjustm
ent.
Day
7Wilson’sdiseased
iagn
osismade.Th
epatient
continuesu
ndergoingmanagem
ento
facuteliver
injury.
Day
10Delivery
ofno
nviablefetus
perfo
rmed.
Day
13Patie
ntrepo
rts“bu
bbleon
gum
thatpo
pped”b
utisasym
ptom
atic.
HDconsultatio
ncompleted
andrevealstoo
th#30(right
mandibu
larm
olar)h
asdraining
sinus
tract.
Day
15
Pulpectomyperfo
rmed
ontooth#30in
hospita
ldentalclin
ic.D
entaln
eeds
forliver
transplant
clearance
area
ssessedandschedu
ledfor
treatmento
nan
outpatient
basis.
Patie
nt’soriginaldentist
iscontactedviatele
phon
eand
relay
sthatp
atient
received
dentaltre
atmento
f10leftpo
sterio
rteeth,including
root
canaltherapy
on3molarsin1v
isit.
Patie
ntdischarged
from
hospita
l.6days
afterhospita
lization
Second
hospita
lization
Day
1Patie
ntpresentsto
EDforw
orsening
andpersistentp
elvicpain.
Patie
ntadmitted
form
anagem
entw
ithGastro
enterology
(GE)
team
andspon
taneou
sbacteria
lperito
nitis
(SBP
)treatmentisinitia
tedand
paracentesiscompleted.
Day
2HDconsultatio
nforp
ost-p
ulpectom
yfollo
w-up.Patie
nt’sdentalcond
ition
isstableandpatie
ntisschedu
ledforfurther
dentalmanagem
ent
onan
outpatient
basis
.Day
3SB
Ptre
atmentd
iscon
tinued.
Day
5Patie
ntdischarged
from
hospita
l.
13days
after
hospita
lization
Day
3Oralm
axillofacialsurgery
(OMFS
)con
sultatio
niscompleted
fore
xtractions
underg
eneralanesthesia.
Day
6OMFS
completes
dentaltre
atmentu
nder
generalanesthesia
(teeth1,14,16,17,and
32extracted).
Third
hospita
lization
Day
1Patie
ntpresentsto
EDfora
bdom
inalpain,n
ausea,anddiarrhea.
Patie
ntadmitted
toadultICU
.Day
2Patie
nt’scond
ition
deterio
ratesa
ndpatie
ntisintubated.
Day
3Patie
ntdiagno
sedwith
portalhypertensiv
egastro
pathyandascites.
Con
tinuedmanagem
ento
fliver
complications
inclu
ding
paracentesisandesop
hagogastrodu
odenoscopy
(diagn
ostic
endo
scop
icprocedure
forv
isualizationof
upperp
ortio
nof
GItract).
Day
5Patie
nt’scond
ition
stabilizesa
ndpatie
ntisextubated.
Day
9Paracentesiscompleted
with
4Lof
fluid
removal.
Day
10Patie
nthasa
nepiso
deof
unrespon
sivenesstoste
rnalrub,requ
iring
1.2IV
Narcanadministratio
nbefore
patie
nt’smentalstatusreturns.Th
isincident
isattributed
toPh
energansedatio
n.Day
17Patie
ntdischarged
from
hospita
l.
4 Case Reports in Dentistry
Table1:Con
tinued.
Date
Event
6days
afterhospita
lization
Fourth
hospita
lization
Day
1Patie
ntadmitted
tolocalE
Daft
erfoun
dun
respon
sivea
thom
e.Patie
nttransfe
rred
toadultICU
andisintubated.
Patie
ntdiagno
sedforseptic
shocksecond
aryto
SBP.
Day
3Patie
ntdiagno
sedforc
ardiac
ischemiawith
developm
ento
fnon
sustainedventric
ular
tachycardia.Multio
rgan
failu
reisob
served.
Patie
ntshow
sintermittentp
rolonged
unsta
blea
rrhythmiawith
ventric
ular
fibrillationandhypo
tension.
Patie
nt’scare
team
discussesp
oorp
rogn
osiswith
family.
Day
4Patie
ntdies.
Case Reports in Dentistry 5
Three days following the extractions, the patient reporteda three-day history of abdominal pain, nausea, and diarrhea.Laboratory studies indicated evidence of leukocytosis, result-ing in admission to the hospital’s adult ICU. The patient wasnewly diagnosed with portal hypertensive gastropathy withascites, due to portal hypertension with SBP. Complicationsled to degradation of her condition requiring intubationand broad-spectrum antibiotic therapy. After one week, hercondition stabilized and she was extubated. Paracentesis wascompleted to remove 4 liters of fluid. An isolated episodeof unresponsiveness to sternal rubbing occurred. This wasmanaged by administration of 1.2mg IV Narcan and laterattributed to Phenergan sedation. After 2.5-week hospitaliza-tion, the patient was discharged.
The following week, the patient was found to be unre-sponsive at her home and was readmitted to the ICU. Shewas observed to be significantly obtunded and jaundicedwithdistended abdomen and remainedminimally responsive. Shewas eventually diagnosed with septic shock secondary toSBP with new onset of acute kidney injury and hypotension.The option to use continuous renal replacement therapy wasdeclined by the patient’s family. On day 2 of her ICU stay,cardiac ischemia was evident with development of nonsus-tained ventricular tachycardia. She developed intermittentprolonged unstable arrhythmia with ventricular fibrillationand hypotension. The maximum amount of norepinephrinewas administered to counter hypotension and heart failure.After the care teamdiscussed the patient’s poor prognosis, herfamily decided to halt further life-sustaining measures. Aftera 3-day ICU course, the patient died.
3. Discussion
Consolidated guidelines have been established by both sep-arate and collaborative medical and dental organizations tofoster and support care integration, particularly for pregnantpatients [1, 5]. Provision of prenatal oral healthcare mustbe managed in a safe and appropriate manner. The quantityof rendered treatment and the postoperative complicationsprompted the initiation of this patient’s course of illness andmay have contributed to exacerbation of liver symptomsin conjunction with her unknown, preexisting condition ofWilson’s disease. Dentists provide expertise and means fordiagnosing, planning, treating, and educating the patient tooptimize oral health. With the provision of dental care, thehealth risks and benefits of providing an extensive amount ofinvasive treatment, regardless of the patient’s pregnancy sta-tus, must be considered. For the pregnant patient, it is criticalto assess the impact of dental treatment during pregnancyin terms of priority (emergent versus routine), quantity,timeliness, medications involved in rendering treatment,ergonomics while undergoing treatment, andmanagement ofposttreatment complications, including pain. It is especiallycritical that the pregnant patient obtains treatment when shepresents with an acute odontogenic infection, as delays cancarry greater risks than those associated with exposure totreatment and medications required for management. Theuse of local anesthetic, modalities of sedation, and analgesiain the pregnant patient has been complex and controversial
[9]. National consensus statements and recent studies haverendered many of these modalities safe when used properly,in consultation with the prenatal provider when needed [1, 5,9, 13].
Medical providers also contribute expertise to the preg-nant patient’s oral healthcare. Just as dental providers musttake themodifications and potential complications associatedwith rendering dental care of any patient into consideration,medical providersmust also address the oral health needs thatmay arise in their own patient management. As a providerwho also consistently manages the patient throughout herpregnancy, the medical provider is able to identify the needfor the patient to be referred for dental care [1, 5, 7, 8, 10].Themedical provider serves as a source of disseminated informa-tion that may encourage prevention and early interventionof oral health problems such that these problems and theirconsequences can be better managed [1, 5]. This providercan also communicate with the dental provider on systemichealth considerations such that care can be rendered safely[1, 5].
Evidence-based dental management of the pregnantpatient continues to be practiced inconsistently [1, 7, 8,10, 11, 14–16]. Many pregnant patients are still unable tofind a dental provider willing to treat them due to remain-ing misconceptions regarding oral healthcare. Concerns ofunfounded risks to the fetus with dental treatment heightenissues of premature induction labor, lack of knowledge inthe safety of treatment, and potential legal risks if negativebirth outcomes occur [4, 6, 8, 10, 11]. These are commonlyperceived deterrents [8, 10]. Limitations based on incorrector insufficient knowledge of perinatal oral healthcare by thetreating dentist have been shown to have the strongest directeffect on preventing pregnant patients from obtaining dentalcare [11]. Dentist-imposed barriers to accessing reasonablecare can lead to deleterious effects and create greater riskmanagement issues.
Medical professionals have similar hesitations whenaddressing their pregnant patients’ dental status. Generalhealth practitioners, midwives, and obstetricians reportedtheir lack of knowledge in understanding the safety of pre-natal dental treatment as the most significant limitation [10].These providers also reported feeling unqualified to addressdental issues due to insufficient familiarity and knowledge onoral health topics [8], highlighting the importance of propertraining and the need to address these topics in medicaland dental curricula. Many educational institutions amongthe health disciplines exhibit organizational infrastructure,logistical barriers, and isolated education that continue tosupport a discord at oddswith current recommendations [13–15, 17].
While each profession maintains management practicesspecific to its discipline, it is significant to acknowledge theinterrelatedness of the health professions and how care coor-dination impacts the pregnant patient’s overall health. Preg-nancy, as a sensitive period in which compromises in oral-systemic health can readily occur, typifies the importance ofestablishing andmaintaining coordination betweenmedicineand dentistry as well as other healthcare professions. Adverseoutcomes occur as a result of discordant care among the
6 Case Reports in Dentistry
health disciplines. Pregnant patients and their fetuses areplaced at greater risks when preventive and intervening ther-apies are not provided in a timely and appropriate manner[1, 4]. In this case, for example, the patient’s unnecessaryplacement on NPO status revealed a misunderstanding andlack of communication between the teams coordinating hercare. As a result, the patient’s treatment was delayed due toher poor disposition. Additionally, missed opportunities forcollaboration reinforced the separation of health disciplinesand the notion of integrated general health in the mindsets ofboth providers and patients.
It is important to recognize that while healthcareproviders carry many responsibilities in managing a patient’shealth, the patient is also an active participant in the out-comes that emerge from care. Acetaminophen, a perinatal-appropriate painmedicationwith a recommendedmaximumdosage of 4 g in a 24-hour period [18], was independentlyprescribed by her medical and dental providers, but misusedby the patient.Thismisuse led to an overdose that precipitatedthe adverse chain of events. As a first-time pregnant, low-income adolescent, this patient belonged to a population thatismore susceptible to adverse health outcomes resulting fromlow health literacy, defined as the “degree to which peoplehave the capacity to obtain, process, and understand basichealth information and services that are needed to makeappropriate health decisions” [6, 7]. Low health literacy hasbeen associated with poorer health knowledge that can beattributed to poorer health behaviors and outcomes [6, 7,19]. While undergoing care to manage complications thatresulted from the overdose, this patient exhibited noncom-pliant behavior that further compromised treatment. Thesekey instances reflect a misunderstanding and misuse on thepatient’s part of the information and resources available toher.
Health literacy is not wholly dictated by the patient’sindividual characteristics such as socioeconomic status andlevel of education; the degree of literacy is influenced byestablished systems of communication for information dis-semination and patient education [19, 20]. Social and culturalmisconceptions about undergoing care during pregnancy [13]and the lack of awareness of their oral health status andits impact on their pregnancy and general health [4, 8] arecontributing barriers that prevent patients from accessingand utilizing care.
Healthcare entails the overall management of the well-being of a patient in aspects of education, treatment, andmaintenance. Historically, dentistry has been a very separatebranch of healthcare [13–17, 21], practiced on different edu-cational infrastructure, clinical management, and financialmodels more than medicine [16]. Unfortunately, the dispar-ities in care that have resulted from persisting separationof disciplines are still evident in modern day healthcarepractices.
Efforts to integrate dentistrywith other health professionshave increased with recognition of oral health implicationsin general health by the medical community, developmentof collaborative medical-dental training, and incorporationof oral health in medical settings. Unfortunately these effortsremain limited in the educational arena, in part because of
the segmented and isolated educational systems between thehealth branches that have fostered gaps in knowledge andclinical practice between oral and general health [22, 23].
A survey of US dental school indicated a willingnessby educators to incorporate prenatal oral health, but clin-ical experiences remain limited. Barriers included lack ofpregnant patients and faculty expertise [24]. Similarly inCanadian dental schools, only 40% of schools report havingdesignated time in their curriculum to cover this topic [25].Initiatives such as the Prenatal Oral Health Program (pOHP)at the University of North Carolina show promise in helpingeducate the next generation of providers in a collaborativeapproach in practice and thereby, improve the quality ofrendered care and patient outcomes [26, 27].
Standardization of coordinated care within clinical andeducational institutions is likely to be a prolonged processwhere results may not be rapidly realized. Attitudinal andbehavioral practice changes of dental providers to address theneeds of high risk populations for adverse health outcomes,aswell as prioritizing collaborative effortswith healthcare col-leagues and educational initiatives across health professionalschools, are essential for tangible, meaningful progress in oralhealth disparities to occur.
4. Conclusion
This case highlights how practice misconceptions, barriersin collaborative care and communication, and insufficienthealth literacy are interconnected and complicated by oneanother. Though specific to the pregnant dental patient, thiscase offers lessons that can be readily translated to any typeof patient, especially other susceptible populations, includingthe frail elderly, patients with medical complexity, and thosewith disabilities. Oral health is one part that contributes tooverall health. As such, it is important to recognize that apatient’s well-being relies on the coordinated efforts of allthe health disciplines. This case report highlights some ofthe challenges of incorporating dental and medical practiceswithin the current healthcare environment. Most prevalentof these issues were the dental and medical providers’ incon-sistencies in patient management, the segmented, noncol-laborative infrastructure of communication and care coor-dination between these providers, and the patient’s lackof knowledge and understanding of her health status. Thecoordinated efforts between specialties made in the latterpart of this patient’s care are evidence that collaboration,albeit challenging, is readily possible and critically necessary.Greater emphases on interprofessional education, practice,and systems changes are needed to help address some of thecurrent clinical challenges and disconnects among healthcareprofessions.
Abbreviations
ED: Emergency departmentNAC: N-AcetylcysteineICU: Intensive care unitObGyn: Obstetrics and gynecologyNPO: Nil per os
Case Reports in Dentistry 7
SBP: Spontaneous bacterial peritonitisGE: GastroenterologyOMFS: Oral and maxillofacial surgery.
Competing Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper.
Acknowledgments
The authors gratefully acknowledge Rachel Tambunan Chu,DDS, Si On Lim,DDS, Jayashree Srinivasan, DMD, andCarolWiese, DDS for their clinical contributions.
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8 Case Reports in Dentistry
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