Liver Function
Secretion of bile for fat absorption Short term sugar storage Breakdown of aged red blood cells with
excretion of bilirubin Synthesis of coagulation factors Drug metabolism
Hepatitis
Inflammation of the liver from any cause Most common causes are viral & alcoholic
– Less frequent causes are mononucleosis, secondary syphilis, TB, acetaminophen overdose, methotrexate, ketoconazole
Acute symptoms– Abdominal pain, nausea, vomiting, fever, malaise, jaundice,
hepatomegaly, splenomegaly– In the recovery phase, hepatomegaly and abnormal liver
functions may persist
Symptoms of chronic liver disease
May be asymptomatic for 10 to 30 years Nonspecific signs
– Fatigue, weight loss, itchiness, right upper quadrant pain
Hepatitis A
Transmission - fecal-oral route Sources - water, shellfish, restaurants Incubation - 15-50 days Serological evidence of infection in 40% of US
populations No chronic carrier state Vaccine and immunoglobulin available
Hepatitis B
Transmission - percutaneous/permucosal High risk groups
healthcare workers, immigrants from Southeast Asia, hemodialysis patients, IV drug users, recipients of blood transfusions, unprotected sex (especially anal) with multiple partners
Incubation - 45-180 days
Hepatitis B
Risk of infection with needle stick injury 6-30% Prevalence of infection in dentists 8%, oral
surgeons 21% 5-10% risk of becoming a chronic carrier Carriers have increased risk of cirrhosis and
hepatocellular carcinoma Vaccine and immunoglobulin available
Hepatitis C
Transmission - mainly percutaneous. Very low risk with sexual transmission
Incubation 14-180 days Risk groups
– mainly IV drug users, and blood transfusion prior to 1992
Risk of infection with needle stick injury 2-8% 80-90% risk of becoming chronic carrier
Hepatitis C
Risk of cirrhosis and hepatocellular carcinoma No active or passive immunization available Treatment is only suggested in certain
subgroups, but it is expensive, takes up to 1 year, has many side effects, and only 10-30% are actually cured
Other Hepatitis Viruses
Hepatitis D– only occurs as a coinfection with B– transmitted both parenterally and sexually
Hepatitis E– resembles hepatitis A, transmitted through the fecal
oral route
Dental management
Difficult to identify all patients through history Many acute cases of Hep B&C are mild Must use infectious precautions for ALL
patients Screening recommended for patients from high
risk groups
Guidelines for blood exposure
From patients with Hep B– determine titer of anti-HBs in the health care
professional– if adequate - no tx needed– if inadequate give HBIG
From patients with Hep C– exposed professional gets baseline and f/u testing
for anti-HCV and liver enzymes
Alcoholic liver disease
Only 10-15% of alcoholics develop cirrhosis Early change - fatty liver Second stage - alcoholic hepatitis Final stage - cirrhosis
End stage liver disease
Esophageal varicies deficiency of Vit K dependant coagulation
factors anemia, leukopenia, thrombocytopenia esophagitis, gastritis endocrine disturbances encephalopathy dementia
Laboratory abnormalities
Increased AST GGT ALT Bilirubin Alk Phos INR
Decreased albumin RBC, WBC, platelets
Dental management - alcoholic liver disease
Beware a second addiction to pain medication - no refills, avoid narcotics and sedatives if possible
Patient may require more local anesthetic or anxiolytic
Dental management - all liver disease
Screen for bleeding tendencies Unpredictable metabolism of specific drugs
Renal function
Control fluid volume Acid-base balance Controls secretion of K, Na, phosphate Excrete wastes Synthesize erythropoietin Activates Vit D Controls blood pressure by secreting renin Metabolizes drugs
Chronic renal failure
Irreversible destruction of the nephrons The kidney can lose about 50% of the
nephrons and still maintain normal function Progressive, most often caused by DM,
hypertension, Glomerulonephritis Various grades of failure depending on GFR
– 50-10 ml/min = moderate– < 10 ml/min = severe
Laboratory assessment
Urinalysis Increased creatinine Increased BUN Changes in Na, K CBC, INR, PTT GFR = (140 - age) X lean wt in KG X.85 if female
72 X serum creatinine
Chronic renal failure
Problems CV - Fluid overload, hypertension GI nausea, diarrhea Neurologic “uremic encephalopathy” Metabolic - Metabolic acidosis, uremia, hypokalemia Hematologic - Anemia, platelet disfunction Immunity - decreased Dermatologic - yellow tinge to skin, pruritis, bruises Renal rickets Fatigue
Medical management
Conservative care – Restrict fluid, K, Na, protein, phosphate– Tx DM, hypertension– Give recombinant human erythropoietin
Hemodialysis– Patients have arteriovenous shunt– Need heparin infusion during dialysis
Peritoneal Dialysis Renal Transplantation
Dental management
Screen for bleeding disorder before surgery Avoid nephrotoxic drugs
NSAIDs – especially ASA Acyclovir High dose acetaminophen
Decrease dosages of drugs mainly metabolized through kidney
Penicillins, erythromycin, opioids
Controversy whether antibiotic prophylaxis needed