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Dental Management of the Medically Complex Patient > Lecture 3- Hepatic Disease > Flashcards

Lecture 3- Hepatic Disease Flashcards

1
Q

Where is the liver located?

A

upper right quadrant

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2
Q

Largest internal organ:

A

liver

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3
Q

Describe the blood supply to the liver:

A

Dual supply
~20% hepatic artery
~80% portal vein

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4
Q

The hepatic artery delivers:

A

oxygenated blood

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5
Q

The portal vein delivers:

A

nutrients

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6
Q

Left and right hepatic ducts form the:

A

common hepatic duct

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7
Q

The common hepatic duct is responsible for:

A

draining bile from liver and transports wastes from the liver and aids in digestion (by releasing bile)

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8
Q

Carries bile from the liver and the gallbladder thorough the pancreas and into the duodenum:

A

Common bile duct

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9
Q

Where does the common bile duct carry bile? (pathway)

A
  1. liver
  2. gallbladder
  3. pancreas
  4. duodenum
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10
Q

The common bile duct is part of the:

A

biliary duct system

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11
Q

The biliary duct system is formed where:

A

the ducts from the liver and gallbladder are joined

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12
Q

Where the ducts and liver and gallbladder join:

A

biliary duct system (common bile duct is part of this)

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13
Q

the hepatic portal vein goes from the ___ to the ___

A

GI system to the liver

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14
Q

Drains venous blood from liver to inferior vena cava and on to the right:

A

hepatic veins

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15
Q

Provides oxygen and nutrition to liver tissues:

A

hepatic artery

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16
Q

Delivers substances absorbed by the GI tract (stomach, intestine, spleen, & pancreas) for metabolic conversion and/or removal in the liver:

A

hepatic portal vein

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17
Q

Cells of the liver=

A

hepatocytes

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18
Q

What is the function of the hepatocytes?

A

synthesize proteins

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19
Q

Hepatocytes are responsible for synthesizing proteins such as:

A
  1. immunoglobulins
  2. albumin
  3. coagulation factors
  4. carrier proteins
  5. growth factors
  6. hormones
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20
Q

In addition to synthesizing proteins, hepatocytes also synthesize:

A

bilirubin

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21
Q

Made from the breakdown of RBCs:

A

bilirubin

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22
Q

How is bilirubin transported to the liver?

A

by being bound to albumin in its unconjugated form

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23
Q

considered the unconjugated form of bilirubin:

A

bilirubin bound to albumin

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24
Q

The liver conjugates bilirubin by unbinding the protein (albumin) & binding it to ____

A

glucose

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25
Q

Bilirubin + albumin =

Bilirubin + glucose =

A

UNconjugated form

conjugated form

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26
Q

The hepatocytes produce bile for:

A

digestion

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27
Q

The hepatocytes produce ____ for fat storage

A

cholesterol

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28
Q

Bilirubin levels can escalate from:

A
  1. blood disorders
  2. chronic liver disease
  3. blockage of bile ducts
  4. Hepatitis (etoH, viral, drug induced)
  5. cirrhosis
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29
Q

Blood disorders that increase bilirubin levels include:

A
  1. hemolytic anemia
  2. sickle cell anemia
  3. inadequate transfusions
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30
Q

Increased bilirubin results in:

A
  1. jaundice
  2. fatigue
  3. cutaneous itch
  4. discolored urine
  5. discolored feces
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31
Q

A function of hepatocytes is to regulate ____.

A

nutrients

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32
Q

Which nutrients are the hepatocytes responsible for regulating?

A
  1. glucose
  2. glycogen
  3. lipids
  4. amino acids
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33
Q

Hepatocytes prepare ___ for excretion

A

drugs

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34
Q

Responsible for drug conjugation and metabolism:

A

hepatocytes

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35
Q

Types of liver damage include:

A
  1. hepatocellular (infiammation and injury)
  2. cholestatic (obstructive)
  3. mixed
  4. cirrhosis (fibrotic, end-stage), acute or crhonic
  5. neoplastic
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36
Q

Damage of the liver caused by inflammation & injury:

A

hepatocellular

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37
Q

Damage to the liver caused by obstruction:

A

cholesstatic

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38
Q

Fibrotic or end-stage liver damage that may be acute or chronic:

A

cirrhosis

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39
Q

Scarring of the liver in which you start losing hepatocytes:

A

cirrhosis

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40
Q

T/F: Hepatocellular carcinoma may be an increased risk in patients who have had many viral diseases

A

true

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41
Q

Signs of liver diseases include:

A
  1. jaundice
  2. ascites
  3. edema
  4. GI bleed
  5. dark urine
  6. light stool
  7. mental confusion
  8. xanthelasma
  9. spider angiomas
  10. palmar erythema
  11. asaterixis
  12. hyperpigmentation
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42
Q

Symptoms of liver disease include:

A
  1. appetite loss
  2. bloating
  3. nausea
  4. RUQ pain
  5. fatigue
  6. mental confusion
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43
Q

What is both a sign and symptoms of liver disease?

A

mental confusion

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44
Q

What is seen in the following image?

A
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45
Q

Fatty cholesterol deposits in the skin that is a good indicator the patient has some sort of liver disease

A

xanthelasma

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45
Q

What is seen in the following image?

A

spider angiomas

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46
Q

Capillary fragility seen in the skin due to lack of clotting factors; increased peripheral endothelial vasculature:

A

spider angiomas

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47
Q

When liver is not metabolizing ammonia from the body, (usually converts ammonia to ammonium so it can be excreted), the ammonia builds up, getting to the brain and causes:

A

asterixis

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48
Q

Asterixis is also known as:

A

flapping tremor

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49
Q

What is a classic sing of hepatic encephalopathy (HE)

A

asterixis

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50
Q

Described asterixis:

A

jerky movements when the hands are extended at wrists

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51
Q

What can be seen in the following image?

A

asterixis

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52
Q

Sign associated with poor ammonium metabolism:

A

Asterixis

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53
Q

A syndrome of altered neurologic function related to dysregulation of metabolism seen almost exclusively in patient with severe liver disease:

A

Hepatic encephalopathy (HE)

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54
Q

HE can be a chronic problem in patients with ___, managed medically to varying degrees of success, punctuated with occasion exacerbations

A

cirrhosis

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55
Q

T/F: Although acute exacerbations of HE are rarely fatal, they are a frequent cause of hospitalizations among patients with cirrhosis

A

True

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56
Q

What are some blood test that determine general liver function:

A
  1. CBC
  2. CMP (comprehensive metabolic panel)
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57
Q

List some SPECIFIC liver function tests:

A
  1. lipid panel
  2. VDRL
  3. PSA (prostate specific antigen)
  4. SARS antigen & antibody
  5. HIV
  6. HEP B
  7. Bleeding times
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58
Q

Test that evaluates the cells that circulate in the blood:

A

CBC

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59
Q

What cells are evaluated on a CBC?

A
  1. RBCs
  2. WBCs
  3. PLTs
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60
Q

A CBC is an indicator of:

A

overall health

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61
Q

A CBC may detect a variety of diseases and conditions including:

A
  1. infection
  2. anemia
  3. leukemia
  4. lymphoma
  5. neutropenia
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62
Q

CMP:

A

Comprehensive metabolic panel

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63
Q

A CMP may also be called:

A

chemical screen or SMAC 14 (sequential multiple analysis - computer)

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64
Q

A CMP consists of ___ blood tests which serve as:

A

14 blood tests; initial broad medical screening tool

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65
Q

A CMP includes:

A
  1. general tests
  2. kidney function assessment
  3. electrolytes
  4. protein tests
  5. liver function assessment
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66
Q

Why are CMPs (chemical screen/SMACs) a good general test for the patients overall health?

A

Because they look at multiple organ systems

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67
Q

In terms of assessing liver function, the following proteins are good indicators of liver health:

A
  1. bilirubin
  2. alkaline phosphatase (ALP)
  3. Transaminases
  4. albumin
  5. globlulin
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68
Q

Bilirubin is a product of:

A

heme breakdown

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69
Q

Increased total bilirubin = increased:

A

severity of liver injury

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70
Q

bilirubin that is insoluble, bound to albumin, not filtered by kidney:

A

unconjugated (indirect)

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71
Q

T/F: With unconjugated bilirubin, increased SERUM is not really indicative or liver disease

A

True

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72
Q

Form of bilirubin that indicates hemolysis, ineffective erythropoiesis (thalassemia, vitamin B deficiency, Gilbert syndrome)

A

unconjugated (indirect)

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73
Q

T/F: With conjugated bilirubin, increased SERUM levels is NOT really indicative of liver disease

A

False- this is indicative of liver disease

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74
Q

The form of bilirubin that is water soluble and excreted by the kidney:

A

conjugated (direct)

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75
Q

All ____ bilirubin is conjugated

A

urine

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76
Q

A protein involved with bone metabolism that is not specific to liver disease but may indicate cholestatic disease

A

Alkaline phosphatase (high)

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77
Q

This protein is altered in multiple disease conditions, but especially bone neoplasms:

A

alkaline phosphatases

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78
Q

AST, ALT, and GGT are all:

A

transaminases (liver enzymes) needed for protein synthesis & specific to liver function

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79
Q

High levels of transaminases (AST, ALT, GGT) indicates:

A

damage to hepatocytes from hepatocellular disease

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80
Q

T/F: High levels of transaminases (AST, ALT, GGT) are individually proportionally reflective of severity of liver damage

A

False- not individually proportionally reflective

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81
Q

What transaminase is more indicative of cholestatic disease (blockage) and alcoholic liver disease?

A

GGT

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82
Q

AST: ALT ratios are more informative; the ____ the ratio, there specific an indicator of hepatic disease

A

lower

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83
Q

Synthesized exclusively by hepatocytes:

84
Q

What is the half life of albumin?

A

18-20 days

85
Q

Hypoalbuminemia is more indicative of ____ but not specific to ____

A

chronic liver disease; liver disease

86
Q

Hypoalbuminemia is not specific to liver disease as it is also involved in:

A
  1. malnutrition
  2. chronic infection
  3. gut disease
87
Q

What are two liver function tests?

A
  1. albumin
  2. prothrombin time
88
Q

The prothrombin time test measures;

A

extrinsic & common pathway

89
Q

The liver produces all coagulation factors except for:

A

VIII (vascular endothelial cells)

90
Q

PT measures factors:

A

1, 2, 5, 7, 10

91
Q

What are the vitamin K dependent coagulation factors?

A

2, 7, 9,10

92
Q

INR is actually

93
Q

What are the 4 A’s that are measured on a CMP?

A
  1. albumin
  2. alkaline phosphatase
  3. ALT
  4. AST
94
Q

What is the B that is measured on a CMP?

95
Q

What are the 4 C’s that are measured on a CMP?

A
  1. calcium
  2. chloride
  3. CO2
  4. creatinine
96
Q

What is the G measured on a CMP?

97
Q

What is the P measured on a CMP?

98
Q

What is the S that is measured on a CMP?

99
Q

What are the two Ts measured on a CMP?

A
  1. Total bilirubin
  2. Total protein
100
Q

All hepatitis viruses are RNA viruses except for ____ which is an enveloped DNA virus

A

Hep B (HBV)

101
Q

Where does the hepatocellular damage from hepatitis viruses come from?

A

host immune response to viral antigens (rather than direct cytopathic effect from virus)

(think of this like an autoimmune disease)

102
Q

List some components of viral hepatitis that cause hepatocellular damage: (think about the host response)

A
  1. cytotoxic T-cells
  2. Proinflammatory cytokines
  3. NK cell response
  4. Antibody-dependent cellular cytotoxicity
103
Q

Viral hepatitis infection may be ___ /___ and ___/___

A

asymptomatic or symptomatic; acute or chronic

104
Q

Chronic hepatitis can lead to:

A
  1. cirrhosis
  2. liver failure
  3. hepatocellular carcinoma
105
Q

What is the risk factor for hepatitis leading to hepatocellular carcinoma?

A

immunosuppression

106
Q

T/F: A patient with hepatitis can have a chronic infection yet be asymptomatic deeming them in the carrier state (low levels)

107
Q

Viral hepatitis is also called _____, and is a ____ pathogen

A

serum hepatitis; blood-borne

108
Q

Describe the transmission of viral hepatitis:

A
  1. parenteral
  2. intimate
  3. sexual
109
Q

The hep B virus can last up to ___ on an infected surface

110
Q

What is the incubation period for Hep B?

A

90 days average

111
Q

Describe the chronicity of Hep B:

A
  • 90% infants
  • 25-50% 1-5
  • Less than 5% adults
112
Q

Is there a vaccination for hep B? If so describe

A

Yes- 3 doses (1 initial, 1 month, 6 months)

113
Q

For the Hep B vaccination, seroconversion is necessary meaning:

A

your body has to have time to develop specific antibodies as a result of immunization

114
Q

In the chronic state of Hep B, the ___ is always present in the body

A

surface antigen

115
Q

What is another name for hep C?

A

cytomegalovirus

116
Q

Dentistry has adopted the ___ against blood borne diseases which has dramatically decreased the incidence of viral spread

A

universal/standard precautions

117
Q

Patients with chronic hep C must stay on ___ for a long time

A

immunosuppression drugs

118
Q

Hepatitis virus where the average prevalence in injection drug users is 53%

119
Q

What population should be screened due to a higher risk of having the hep C virus?

A

baby boomers

120
Q

___% of untreated hep C patients are able to clear the virus

121
Q

Hep C has a high risk for becoming ____ (75-85%)

122
Q

10-20% of patients who have chronic hep C develop:

A

cirrhosis (takes 20-30 years)

123
Q

Patients who have chronic hep C are at an increased risk for: (2)

A
  1. hepatocellular carcinoma (HCC)
  2. death
124
Q

T/F: HIV has a higher needle stick transmission rate than HCV

A

False- HCV higher

125
Q

Is there a vaccine for Hep C? If so describe

126
Q

What is considered a “cure” for HCV?

A

undetectable HCV RNA levels after 12 weeks of recommended protease inhibitor therapy

127
Q

List some examples of the protease inhibitor therapy (immunosuppression drugs) used to treat hep C:

A
  1. Mavyret
  2. Epclusa
  3. Harvoni
128
Q

T/F: There are chronic carriers associated with hep C

129
Q

Form of hepatitis that usually presents coinfection with Hep B:

A

Hep D (HDV)

130
Q

Compare the severity of Hep B versus Hep B+D

A

Hep B+D is more severe than Hep B alone

131
Q

With Hep D, one is at risk for ____ which results in:

A

fulminant hepatits; massive hepatocellular destruction

132
Q

What hepatitis viruses are considered blood borne?

A

Hep B, C, D

133
Q

What hepatitis viruses are considered fecal-oral borne?

A

Hep A & Hep E

134
Q

Infectious hepatitis, fecal-oral transmission:

135
Q

Hep A and Hep E are considered highly ___ & ___

A

contagious and transmissable

136
Q

Is there a vaccine for Hep A or Hep E? If so describe:

A

Yes for hep A; not for hep E

137
Q

T/F: Most carries of HBV, HCV, and HDV are unaware they have hepatitis

138
Q

T/F: Hepatitis can be contracted by the dentist from an infected patient

139
Q

Chronic, active hepatitis patients may have chronic liver dysfunction such as:

A
  1. increased bleeding
  2. altered drug metabolism
140
Q

Hep ___ is the most likely viral hepatitis to be transmitted occupationally to a dental health care worker followed by Hep ___.

A

Hep B; Hep C

141
Q

T/F: There is little to no risk exists for transmission, for HAV, HEV, and non-A-E hepatitis viruses

142
Q

When we consider ALL patients infectious:

A

Universal precautions

143
Q

If active hep disease status, a risk for dental care in patients with hep virus is:

A

they likely are not making the blood clotting factors

144
Q

How would you respond to the following situation?

Patients with ACTIVE hepatitis (acute or chronic)

A
  1. defer all elective dental treatment
  2. if emergency treatment
    - consult physician
    - determine severity of disease
    - determine dental treatment risk
    - consider referral to specialized center
    - isolation may be necessary
145
Q

How would you respond to the following situation?

Patients with history of hepatitis (resolved, chronic inactive)

A
  1. consider risk factors
  2. consult physician to determine liver status
146
Q

How would you respond to the following situation?

Needle stick

A
  1. consult the physician
  2. consider hepatitis B immunoglobulin
147
Q

What are some viral hepatitis oral manifestations?

A
  1. bleeding
  2. mucosal jaundice
  3. glossitis
  4. angular cheilosis
148
Q

What is an oral manifestation we may see in a patient with chronic HCV?

A
  1. oral lichen Plans
  2. lymphocytic sialadenitis
149
Q

An oral manifestation of hepatitis viruses that is usually part of the immune suppression from the lack of production of immunoglobulins that presents clinically as a fungal or bacterial infection at the corners of the mouth:

A

angular cheilosis

150
Q

Viral hepatitis oral manifestation in which the patient has enlarged parotid glands (Sjogren-like syndrome). What is this due to?

A

Lymphocytic sialodenitis; lymphocytic infiltration and edema in the parotid glands

151
Q

Type of hepatitis in which there is no virus inducing the response:

A

autoimmune hepatitis

152
Q

What is the cause of autoimmune hepatitis?

A

Idiopathic

153
Q

Autoimmune hepatitis is more severe in what population?

154
Q

What is one of the main contributors to drug induced liver disease?

155
Q

List some mechanisms that result in drug-induced liver disease?

A
  1. DIRECT toxicity to hepatocytes
  2. Production of hepatotoxic metabolites
  3. Accumulation of drug due to altered metabolism
156
Q

Degeneration of the liver caused by atrophy of hepatocytes; where scarring and connective take over the liver:

A

Non-alcoholic fatty liver disease (not caused by drugs or alcohol)

157
Q

alcohol and its metabolite are :

A

hepatotoxic

158
Q

alcohol causes ____ which compounds the liver damage

A

inflammation

159
Q

It typically takes ___ of excessive alcohol intake to develop alcoholic liver disease

160
Q

What is the first stage of alcoholic liver disease? Describe

A

Patients first develop fatty liver disease; reversible

161
Q

When a patient has developed fatty liver disease from alcohol and continues alcohol use, this can lead to:

A

irreversible changes & necrosis (due to persistent inflammation)

162
Q

Once a patient has reached the stage of irreversible changes and necrosis of the liver due to alcohol use and continues alcohol use, eventually ____ & ____ develop which is irreversible and leads to ____.

A

fibrosis & cirrhosis; hepatic failure

163
Q

Complications of alcoholic liver disease include:

A
  1. bleeding tendencies
  2. unpredictable drug metabolism
  3. impaired immune function
  4. peripheral neuropathies
  5. dementia & psychosis
  6. anorexia
164
Q

Complications of cirrhosis (due to alcohol) include:

A
  1. ascites
  2. esophageal varices
  3. jaundice
  4. hepatosplenomegaly
  5. coagulation disorders
  6. hypoalbuminemia
  7. anemia
  8. neutropenia
  9. encephalopathy
165
Q

Describe ascites:

A

hepatorenal syndrome (beer belly appearance)

166
Q

Describe esophageal varices:

167
Q

Describe hepatosplenomegaly:

A
  1. enlarged spleen due to portal hypertension
  2. decreased platelet function
  3. leads to thrombocytopenia
168
Q

Describe the coagulation disorders associated with cirrhosis (alcohol induced)

A
  1. decreased synthesis of clotting factors
  2. impaired clearance of anticoagulations
  3. decreased vitamin K absorption
169
Q

VItamin K absorption requires:

A

biliary excretion

170
Q

Describe the anemia that is a complication of cirrhosis (alcohol induced):

A
  1. iron deficiency
  2. macrocytosis
171
Q

Describe encephalopathy that is a complication of cirrhosis (alcohol induced):

A

Neurotoxins not removed from the liver

172
Q

How might you identify a patients alcoholism?

A
  1. history
  2. clinical examination
  3. detection of odor on breath
  4. suspicious behavior
  5. info from family/friend
173
Q

What is the BEST way to identify a patients alcoholism?

174
Q

What is a problem for the dentist with a patient who has early on/mild liver dysfunction caused by alcohol?

A

Liver enzyme induction may increase metabolism of prescribe drugs, limiting their effect

175
Q

What is a problem for the dentist with a patient who has early on/mild liver dysfunction caused by alcohol?

A

Drug metabolism may conversely be hindered and drug toxicity is a concern

176
Q

In many chronic liver diseases, the ratio of AST: ALT is ___ where as in alcoholics the ratio of AST: ALT is much _____

A

low; higher

177
Q

What is the AST: ALT ratio in a patient with alcoholism?

A

Greater than or equal to 2

178
Q

A patient presents with AST: ALT ratio of 2.4 and an elevated GGT. What might you suspect?

A

alcoholic liver disease

179
Q

Total protein-

Hepatitis:

Cirrhosis:

A

Hepatitis: Normal

Cirrhosis: Decreased

180
Q

Albumin-

Hepatitis:

Cirrhosis:

A

Hepatitis: Normal

Cirrhosis: Decreased

181
Q

Globulin-

Hepatitis:

Cirrhosis:

A

Hepatitis: Normal

Cirrhosis: Increased

182
Q

A/G Ratio

Hepatitis:

Cirrhosis:

A

Hepatitis: greater than 1

Cirrhosis: Less than 1

183
Q

Alkaline phosphatase-

Hepatitis:

Cirrhosis:

A

Hepatitis: elevated 1-2 times normal

Cirrhosis: elevated 1-2 times normal

184
Q

ALT-

Hepatitis:

Cirrhosis:

A

Hepatitis: Values increased into the thousands

Cirrhosis: ALT, AST are increase up to a maximum of 300 IU

185
Q

AST-

Hepatitis:

Cirrhosis:

A

Hepatitis: values increased to the thousands but ALT is ALWAYS greater than AST

Cirrhosis: NEVER greater than 300 IU AST is always greater than ALT

186
Q

Alcoholic liver disease oral manifestations include:

A
  1. neglect
  2. bleeding
  3. ecchymoses
  4. petechiae
  5. glossitis
  6. angular cheilosis
  7. alcohol odor
  8. parotid enlargement
  9. xerostomia
187
Q

A patient with jaundice mucosal tissues and a breath that is ___ & ___ is associated with liver failure

A

sweet & musty

188
Q

Alcohol is a STRONG risk factor for:

A

oral squamous carcinoma

189
Q

_____ is the number one abused drug in terms of ER visits, hospital admission, family violence and social problems

A

alcohol abuse

190
Q

Laboratory tests may be needed to evaluate the fitness of the patient for dental treatment(s). If we suspect liver disease, what lab tests may we order?

A
  1. CBC with differential (this includes platelets)
  2. Liver function test which includes
    - AST
    - ALT
    - GGT
    - Albumin
    - Alkaline phosphatase
    - Bilirubin
191
Q

T/F: In a patient with significant liver disease SRP should be done one quadrant at a time, not the full mouth.

A

False- SRP should be one tooth at a time rather an entire quadrant

192
Q

In a patient with significant liver disease, what should you avoid post-op?

A

NO NSAIDS for pain management

193
Q

In a patient with significant liver disease, what CAN you recommend post-op for pain control?

A

acetaminophen up to 2g daily

194
Q

T/F: Antibiotic prophylaxis prior to dental procedures is NOT required if no oral infection is present in a patient with liver disease. Patients with SEVERE LIVER DISEASE may need antibiotic prophylaxis for invasive/surgical procedures due to decreased immune function.

A

Both statements true

195
Q

For patients with liver disease, you should minimize use of drugs metabolized by the liver. These drugs include:

A
  1. local anesthetic
  2. analgesics
  3. sedative
  4. antimicrobials
196
Q

What is a concern with local anesthetics in patients with liver disease?

A

Local anesthetics are not metabolized properly by the liver and may result in encephalopathy

197
Q

What may be a better option as opposed to amide anesthetics in a patient with liver disease?

A

Ester anesthetics (but can be hard to find & not as long last for pain control)

198
Q

Opioids can be used if necessary for post-op pain control in a liver diseased person. Which ones would we avoid? Which should we prescribe?

A

AVOID: hydrocodone & oxycodone

PRESCRIBE: Hydromorphone

199
Q

What sedatives should be avoided in a person with liver disease? Which are acceptable?

A

AVOID: benzodiazepines

Potentially use: Lorazepam due to its shortened half life

N2O is a safer option if possible

200
Q

What antimicrobials should be avoided in a person with liver disease? Which are acceptable?

A

AVOID: Metronidazole, Tetracycline, Doxycycline, Fluconazole – these get broken down in liver

Possible issue with: Clindamycin

201
Q

Disulfiram effect:

A

antimicrobial alcohols take to make them violently ill with alcohol

202
Q

Type of hypertension that is a complication with cirrhosis:

A

portal hypertension

203
Q

What is significantly elevated with portal hypertension?

204
Q

With portal hypertension, ___ should be limited as well as no use of retraction cord with ____.

205
Q

Why do we see thrombocytopenia with portal hypertension?

A

due to platelet sequestration in the spleen

206
Q

What risk ratio should we weigh when deciding to prescribe antibiotics prophylactically

A

impairment of drug metabolism vs. immune impairment

207
Q

T/F: Antibiotic prophylaxis is a consideration in a patient with liver disease

Dental Management of the Medically Complex Patient (5 decks)

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