Lecture No : 4

Date : 4-3-2015

Doctor : Yazan Hassoneh

Done by : Kefah Al-Soud

Kefah Alsoud oral medicine sheet #4 4-3-2015 (Wednesday)

Liver diseases in Dentisrty) )

Liver is important organ because : 1) it makes the metabolism of the drugs ..2) storage of vitamins and glycogen 3) synthesis of growth factors , proteins and hormones .. so liver is vital organ .. vital organ means : liver, kidney, heart ,lung and brain

*so disease of liver has implications in dentistry which include : 1 )impaired drugs metabolism .. pt has bleeding tendency

2 )risk of transmission of infections particularly hepatitis

Hepatitis A : It is very common .. affect children in the schools , Acute infection and usually it is mild disease

*it's symptoms are non-specific like any other viral infection

*it caused by Hepatitis A virus : RNA virus , mainly transmitted through feco-oral route .. this means it transmitted through foods and mainly affected child in the schools .. so people who work in restaurants must make test to check about hepatitis virus

*Incubation period : 2-3 weeks after initial infection

*clinical symptoms : like any other viral infection include : 1- mild fever 2- fatigue and Nausea 3- general weakness(like common cold symptoms ) 4- child will has jaundice 5-dark urine 5- clay color stone

*it has little infection hazard in dentistry (not transmitted by saliva)

Dignosis : pt is positive for IgM antibody against Hepatitis A virus.. and there is elevation in liver enzymes (in All hepatitis there is increase in liver enzymes)

*Management : symptomatic management include : 1- bed rest 2- fluid intake 3- low fat diet 4- Analgesics 5- Antipyretic

-Why Drs advice these pt to eat sweety foods (7alawe for ex) ?? To give them source for energy other than fat ( carbohydrates not metablised a lot in liver )

*Oral manifestation : no Oral manifestation just jaundice -it may cause : halitosis and coated tongue

-dentist must postpone dental trt until cure occurs -there is possibility of salivary transmission , but the major one

is feco-oral route

***Hepatitis B and C are the most important thypes of hepatitis virus

-the inection may be : acute or chronic

Hepatitis B *DNA virus transmitted through body fluid ( blood and sexual

transmission and saliva "parenatal" ) *there is some groups in particular risk like : 1) IV drugs abuse

who have ( 3laj ble 2br el 9eneeh ) 2) people who work in health care centers : DENTIST ! 3) Blood transfusion : in pt with sickle cell anemia and hemophilia 4) pt who make tattoo 5) dialyisis pt

*dentist must take vaccine against hepatitis because they are in direct contact with pts

**Clinical features : it is subclinical in 50% of cases this means no symptoms ,, you may have needle stick injury and hepatitis may transmitted to you without any symptoms appear

* incubation period : 2-3 months if symptoms appear they are like any symptoms of hepatitis (fatigue , jaundice, fever ,nausea, dark urine, clay color stone >> because of bilurbin )

*if chronic infection occurs pts will be at high risk for certain complications : 1) cirrhosis 2) Hepatocellular carcinoma and 3) liver failure ,, so the main issue that severe pt develop chronic hepatitis and become carriers for the virus

*Dignosis : based on clinical features there is increase in liver enzymes and the pt has positive serology for HBs( surface Ag) and E Ag so the pt is highly infectious if he has HBs Ag or E Ag

*hepatitis serelogy >> Anti HBc : mean privous infection *Anti HBs : immunity and vaccination against HB virus

*sometimes Drs make titer by PCR (polymerase chain reaction ) to know the risk constituent

*Acute hepatitis has no treatment just symptomatic management (bed rest , fluid intake and dietary changes

*chronic : give them interferon alpha or Antiviral (it is not effective in all situations "in low percentage" )

**Hepatitis B has no oral manifestation but the main issue in dental treatment is cross inection ( e7temalet el e9aba with needle stick injury in hepatitis B from infective pt is about 6-40 % )

**HB s Ag is found in saliva so salivary transmission may occurs although it is unlikely but saliva isn't pure fluid it has certain amount of blood , gingival exudates or after extaction and during dental treatment so transmission may occur in saliva

**some people take vaccine but their bodies are resistant so there is no benefit from this vaccine ,,any one expose to cross infection Drs

must redo hepatitis test and give them another vaccine again !

**if chronic hepatitis B it may convert to liver disease ( cirrhosis or hepatocellular carcinoma ) and they have certain dental aspects

** Hepatitis C :

Differ from the other that this has chronic tendency to cause chronic infection ( most infectious and asymptomatic )

-it is RNA virus (remember B is DNA virus)

-transmitted through body fluid or parental (like HB ) or by drugs

Dignosis :

By antibody .. pt has hepatitis C or Anti hepatitis C antibody (previously exposed to hepatitis C )

-like another viral infection can be detected by PCR to see any RNA (VIRAL PARTICLES )

Treatment : give them alpha interferon and antiviral (not always effective) : cure not exceed 20% !

**HC virus differ from other Heatitis virus that has oral manifestation , if pt is infective then he has oral manifestation include : 1) xerostomia

2) swelling of parotid gland 3) lichen planus 4) sjorgen syndrome ..

*Egyptians have lichen planus is highly associated with hepatitis C infection

**HC is less infective than B 2-6% (after needle stick injury) but it is more dangerous because there is no vaccine for HC although HB has vaccine ( so treatment for hepatitis C virus need certain Cautious

**every virus has certain infectivity depend on : it's nature , shape , and if there is membrane or not

Chronic liver disease 1 )liver cirrhosis :t$m3 el kbd

Replacement of liver tissue with fibrosis or scars this caused by hepatitis virus or alcohol consumption or from certain drugs or autoimmune disease

**Complication : 1) portal hypertension 2) hepatoencephelopathy (pt will enter in coma ) 3) hepatocellular carcinoma 4) bleeding tendency 5) Diabetes and this occurs because : liver failure lead to fibrosis so liver will not able to restore glycogen and will convert it to glucose

**A lot of causes include :

1 )viral causes 2) excessive consumption of alcohol 3) hepatotoxic drugs include paracetamol overdose 4) autoimmune disease 5) wilson's disease (abnormal deposition of copper in liver ) 6) alpha antitrypsin deficiency ( emphysema is another disease caused by this)

**clinical features : liver cirrhosis : pt who has end stage of disease has certain feature in addition to non-specific features include : fatigue ,weight loss ,weakness and abdominal distension(asities) .. finger clipping, contraction for little and ring finger .. and jaundice and palmer erthmya (redness in the palms of hands) , pigmentation of skin and oral mucosa ,, easy brusing because of deficiency in clot factor ,, loss of hair

**diagnosis: - measure of liver enzymes ( hepatic serology test )

-autoimmune profile : to know if the pt has any autoimmune disease

-iron and copper level : to exclude any hemochromastosis ,, increase in iron level with chronic liver disease >> this is called hemochromastosis

-copper increase in wilson's disease

**Management : it is difficult ,, liver failure in the end and in severe cases end up with liver transplant

-remove the underlying causes – avoid alcohol and hepatotoxic drugs --- adequate nutrition (last year sheet)

**Oral manifestation of chronic liver disease : 1) sialosis "bilateral enlargement of salivary glands 2) bleeding tendency of oral mucosa 3) jaundice 4)bad smile "halitosis " 5)nutritional deficiency : glossitis . angular chillites and aphthous ulcer 6)lichen planus

Lack of synthesis of proteins so pt will have oral ulcer and glossitis

7)bleeding tendency : must do measuring for INR for clotting factor before dental treatment AND must do CBC

**impaired drug metabolism analgesics , sedative and antibiotics

**Analgesics : paracetamol and opoids are contraindicated

Give them NSAID : but with low doses

**Antibiotic : 1) Amoxicllin : common and safe we can use them

2 )erythrmyocin : is contraindicated

**GA is contraindicated : must give LA ( last year sheet )

Hepatitis D : weak virus not cause infection lone unless pt has HB virus ( co-infectious with HB virus)

Hepatitis E : less common , like HA

GI disease :

They are important and they have dental aspects they include :

1 )GE reflux disease and peptic ulcer

2 )inflammatory bowel disease ,,a) crohns disease .. b) ulcerative colitis

3 )celic disease and pseduomembranous colitis

Gastroesophageal reflux disease: ertedad mre2i : characterized by regurgitation of gastric contents into esophagus ,, if the problem was chronic metaplasia will occur in esophageal cells(barrett esophagous) .. they will convert from columnar to squamous .. so it is potentially malignant condition

**Risk factors : smoking , obesity , stress , heavy meals

**symptoms : nausea, dysphagia, chest pain ,, and chronic cough this caused by acid regurgitation that cause irritation to the larynx .. first you think about respiratory problem but it not dyspnea because there is regurgitation of gastric contents

Diagnosis : through clinical features***:

-endoscopy and PH monitoring

-diet changes : pt less likely to change his diet so give them medications which include : Anti acid , proton pump inhibitor and

histamine blocker..

-erosion may occur in palatal surfaces of the teeth

-xerostomia because of : antihistamine and proton pump inhibitor

-erthyma in the palate : irritation from acids

-Antiacid and Antihistamine : contrary with systemic antifungal medication

-the problem in GE reflux is in the sphincter (esophageal sphincter) : it is incompetent ,, so acid will regurgate

** PEPTIC ULCER :

Caused by infection from bacteria called : helicobacter pylori ( elbacteria alhalazonee) it is common disease affect duodenum and gastric mucosa caused ulcer

**risk factor : infection by helicobacter pylori , stress , smoking , chronic use of steroid , hyperparathyroidism and chronic renal failure

**epigastric pain is classical symptom of peptic ulcer (wj3 fe ras elm3de) ,, GI hemorrhage in advanced cases(cause anemia) , vomiting, .. indigestion

**if male comes to your clinic with iron deficiency anemia (40 yrs old) you must think of serious causes of blood loss like : GI malignancy or peptic ulcer so if he comes with glossitis or ulcer you must advice him to make CBC and to check Iron level

**Management : similar to GE reflux disease but must take Antibiotic .. triple therapy which include : 2 antibiotic and proton pump inhibitor .. for one week to eradicate the infection

-Give them : amolcan and omeprazole

**Dental aspects: 1) erosions 2) xerostomia : side effects of medx

3 )glossitis (nutritional deficiency )

*NSAID : are contraindicated because they increase the risk of ulceration

**Drug interaction : between erthromycin and tetracycline with antacid .. if you give them antacids and you decide to give antibiotic it is more preferable to give them amoxicillin ,, if you decide to give erthromycin

give it 1 or 2 hours after antacid

** crohn's disease : Chronic granulmatous disease affect ileum and cecum (mainly affect large intestines) .. common disease with high mortality 15 % (death due to the disease itself)

-symptoms : fever , weight loss, diarrhea, vomiting , systemic ulcer and symptoms related to malnutrition and abdominal pain

-pt takes steroid (it is inflammatory disease ) so give immunosuppressant like steroid ,, sometimes pts will have surgery to

remove the infectious part that affected by the disease..

-they need steroid cover

-give them prophylaxis antibiotic accorging to the procedure

-Due to the medx they take : liver damage will occur

-NSAID are contraindicated

-if the pt has crohns disease and comes with exsicion of some part of the intestine they will complicate from deficiency and bleeding tendency

** Ulceritive colitis :

Similar to crohns disease so must do (Biopsy) from colon to differentiate

-Dental aspects : ulcerative colitis: pustules and vegetation in oral cavity (contains pus) ,, multiples vacuoles if it will be infected it will cause aphthous ulcer . nutritional deficiency and glossitis

**Celic disease: (hasaset el8mh) , gluten intolerance .. caused atrophy in the intestines ..and this atrophy caused malabsorbtion ,, affect young people : so the child appear thin with diarrhea and they don't

eat ,,

**there is familial tendency for certain human leukocyte gene ,, but the main cause for this disease is unknown until now

-clinical features : non-specific (so the diagnosis will be later) : steatorrhea(fatty stool) , malabsorbtion , skin rash (dermatitis herpetiformis) , and abdominal pain

**management : mainly not medical( take gluten free diet ) the avoid to eat wheat .. and they buy corn bread

**Dental aspect : aphthous like ulcer , enamel hypoplasia and bleeding tendency and vitamin K deficiency

pseudomembranous colitis

Severe colitis results as side effects from certain medication and due to bacteria called : (colistridum difficle)..

-mainly affect the elderly and the hospitalized pt(due to release of entertoxins) .. mainly occur from widely used ( broad spectrum antibiotic)

-all antibiotic may cause this disease : clindamycin and many other

-clinica features : watery diarrhea , bloody diarrhea in severe cases , fever , abdominal pain

So the clinical features based on the history of the pt :

1 )Must make stone culture : to exclude the infection … 2)endoscopy or sigmoidscopy ?

**management is : 1) to stop the antibiotic 2) fluid and electrolyte replacement in severe cases give : vancomycin and metranedazole .. vancomycin(not given orally >> not absorbed in the stomach and intestine so there is no systemic absorbtion ) SO give it topically

**Dental aspect : broad spectrum antibiotic may cause candidiosis ,, the dentist must recognize the sign and symptoms and treat them

accordingly..

Work Hard! ); ..