Dental Aspects of Hepatitis

• Implications:

  • Cross-infection
  • Bleeding
  • Anaesthesia/drugs
• Common causes of hepatitis:

  • Viral infections
  • Hepatitis A, B and C
  • Epstein-Barr Virus (glandular fever/infectious mononucleosis)
  • Drug reaction (paracetamol)
  • 4g maximum per 24 hours
  • 10-15g -> acute liver damage
  • 25g invariably fatal
• Uncommon and rare causes of hepatitis:

  • Uncommon
  • Autoimmune
  • Rare
  • Wilson's disease (liver problem) - raised copper, liver can't metabolise or excrete it
  • Toxins
• Causes of acute hepatitis - self-limiting liver inflammation:

  • Viral
  • Acute alcoholic hepatitis
  • Drugs
  • Toxins
  • Medications
• Investigations of acute hepatitis - self-limiting liver inflammation:

  • LFTs (liver function tests) - check hepatic enzymes
  • Tests to determine cause - viral serology, immunoglobulins, autoantibody profile
  • Liver ultrasonography
• Chronic liver disease:

  • Clinical features of cirrhosis seen (initial compensation)
  • Causes include Chronic Hepatitis C and alcohol abuse
  • Signs and symptoms are due to:
  • Liver fibrosis
  • Reduced liver cell mass
  • Portal hypertension
• Chronic liver disease:

  • Reduced liver cell mass problems:
  • Encephalopathy
  • Reduced attention span
  • Reverse sleeping pattern
  • Loss of lean body mass - shoulders
  • Accumulation of body water
  • Coagulopathy
• History of pt with hepatitis:

  • Jaundice (caused by deposition of bile salts in tissues)
  • Alcohol intake
  • Known infection
  • History of drug intolerance
  • Bleeding disorders (other causes)
  • IVDU (intravenous drug use)
  • Sexual history
• Examination of pt with hepatitis:

  • Jaundice
  • Bruising
  • Spider naevi
  • Liver flap aka 'asterixis'
  • Asterixis is a tremor of the hand when the hand is extended (dorsiflexion), sometimes said to resemble a bird flapping its wings
  • Scratch marks (due to deposition of bile salts making skin itch)
  • Sialosis (non-inflammatory and non-neoplastic enlargement of salivary glands)
  • Dupuytren's contracture (3rd, 4th, 5th fingers are bent at rest)
  • Palmar erythema (red palms)
  • Gynaecomastia (development of breast tissue in males because oestrogen isn't metabolised)

  
• Liver function tests (LFTs):

  • ALT (alanine transaminase) - if raised suggests problems with liver cell integrity
  • AST (aspartate transaminase) - if raised suggests problems with liver cell integrity
  • Clotting (not a LFT, it's a surrogate marker for liver function)
  • Gamma glutamyl transpeptidase (raised in pts who have long-term excess alcohol intake - helps to differentiate between alcohol-related issues and those not related to alcohol)
  • Alkaline phosphatase (in obstructive jaundice - non-specific)
• Bleeding in pts with hepatitis:

  • History
  • Cues on examination
  • May need FFP (fresh frozen plasma) perioperatively to facilitate surgical treatment
  • Would have to have seen a specialist about their condition first though
• Cross-infection:

  • Immunisation Hepatitis B
  • DELTOID INJECTION 3 doses
  • Initial dose then repeated at 1 & 6 month serology
  • Booster - depending on serological markers
  • Aim for >100 IU/L (imperial units per litre) - implies long term immunity
  • Hand washing - hepatitis A, MRSA, C. difficile
  • Avoidance of needlestick
  • Masks, spectacles, gloves (double)
• Serological markers for hepatitis B:

  • Hep B surface antigen
  • 1st manifestation of infection!
  • Marker of ongoing infectivity
  • Anti Hep B surface antigen
  • Protection from infection
  • Hep B core antigen
  • Detected by development of antibody
  • Signifies donor infectivity if Hep B surface antigen negative but Hep B core antigen positive
  • Anti Hep B surface antigen and Anti Hep B core antigen signifies previous infection
  • Hep B e antigen
  • Only found if Hep B surface antigen positive (an index of infectivity)
  • Shows active viral replication
• Drugs and anaesthetics are metabolised by the liver - so if someone has liver problems then their metabolism might not be adequate:

  • Severe jaundice undergoing GA may lead to hepato-renal syndrome
  • Renal (kidney) failure secondary to liver failure
  • LA - amide biotransforms in liver
  • Articaine, Prilocaine = possible better options (because of partial metabolism in the lungs)
  • Limit lidocaine to 2 cartridges
• Drugs and anaesthetics are metabolised by the liver - so if someone has liver problems then their metabolism might not be adequate:

  • Sedation in cirrhosis - specialised units as small doses may lead to coma - best avoided
  • Miconazole is completely contraindicated
  • Fluconazole - decreased dose
  • Avoid erythromycin, metronidazole and tetracycline
  • NSAIDs (like ibuprofen) best avoided - risk of gastrointestinal bleeding
  • Avoid paracetamol
• Alcoholic patients:

  • Risk of haematemesis (vomiting of blood) due to portal hypertension
  • Many pts take prophylactic beta blockers e.g. propranolol
  • Reduced plasma clearance of epinephrine
  • Unopposed alpha adrenergic effects
  • Hypertensive crisis
  • Bleeding
  • Low platelet count