Lecture 3b: Liver disease

Question 1

Length of preicteric phase

Answer 1

3 - 10 days

Question 2

4 clinical manifestations of the preicteric phase

Answer 2

Fatigue
Nausea
Poor appetite
Vague R Upper quadrant pain

Question 3

4 clinical manifestations of icteric phase

Answer 3

Production of dark urine
Jaundice appears
Hepatic tenderness
Symptoms worse

Question 4

4 general manifestations of liver disease relating to oral health

Answer 4

Anorexia
Dysgeusia
Weight loss
Easy bruising/petechia

Question 5

Risk of acquiring hepatitis as a dentist relative to general population

Answer 5

3 - 10 times

Question 6

To whom are HBV booster doses given?

Answer 6

Only to people who did not respond to the primary vaccination series

Question 7

HBV exposure protocol for vaccinated care provider (i.e. if stuck by a contaminated needle)

Answer 7

Should be tested for adequate titer of anti-HBs if levels are unknown
• Adequate –> nothing further is required
• Inadequate –> immediately receive an injection of HBIG and vaccine booster dose (30 % risk of contracting HBV infection from HBV carriers)

Question 8

HBV exposure protocol for unvaccinated persons

Answer 8

Immediate HBIG injection and vaccine

Question 9

HCV exposure protocol

Answer 9

• No postexposure protocol or vaccine is available
• Source person = baseline testing for anti HCV
• Exposed persons receive baseline and f/u testing at 6 mo for anti HCV and liver enzyme activity

Question 10

4 analgesics to avoid in patient with liver disease

Answer 10

NSAIDs (incl. acetaminophen, aspirin)
Codeine
Meperidine

Question 11

2 antibiotics to avoid in patient with liver disease

Answer 11

Metronidazole

Vancomycin

Question 12

Antibiotic prophylaxis recommendations for patients with liver disease

Answer 12

Not recommended

However, patients with severe liver disease may be more susceptible tor infection

Question 13

Anesthesia recommendations for patients with liver disease

Answer 13

Higher doses may be required to achieve adequate anesthesia in presence of alcoholic liver disease (must know liver function)

Epinephrine (1:100,000, no more than 2 carpules) for local generally not associated with problems, but monitor closely (especially if portal hypertension)

Question 14

Anti-anxiety medication to avoid in patient with liver disease

Answer 14

Benzodiazepines

Question 15

Bleeding considerations for patient with liver disease

Answer 15

May need vitamin K and/or platelet or clotting factor replacement to reduce risk of post-surgical bleeding

Question 16

9 drugs to avoid in patient with liver disease

Answer 16

Acetaminophen
Aspirin
Ibuprofen
Codeine
Meperidine
Diazepam
Barbiturates
Metronidazole
Vancomycin

Question 17

Protocol for patient with history of alcohol abuse

Answer 17

MD consult for liver status

Question 18

Reason for increased risk of infection in patient with alcoholic liver disease

Answer 18

Impairment of Kupffer cell function and T cell response

Question 19

Antibiotic prophylaxis recommendation for patient with alcoholic liver disease

Answer 19

Not needed IF oral infection is absent

Question 20

Dental management of patient with ACTIVE hepatitis (5 points)

Answer 20

• No dental treatment other than urgent care (ABSOLUTELY NECESSARY WORK), unless patient has attained clinical and biochemical recovery
• If urgent care, provided only in an isolated operatory with strict adherence to standard precautions
• Aerosols should be minimized
• Drug metabolized in liver should be avoided if possible
• If sx – preop PT, if abnormal MD consult

Question 21

2 points of dental management for patient with signs or symptoms of hepatitis

Answer 21

• No elective dental treatment

* Refer to MD consult

Question 22

10 types of patients with substantial risk for Hep B and who should get the vaccine

Answer 22

Health care workers
Public safety workers
Hemodialysis patients
Recipients of certain blood products
Household contacts and sex partners of HBV carriers
Adoptees from countries where HBV infection is endemic
International travellers
Illicit drug users
Sexually active people
Prisoners

Question 23

4 local anesthetics metabolized by the liver

Answer 23

Lidocaine
Mepivacaine
Prilocaine
Bupivacaine

Question 24

Drug administration protocol for patient with chronic active hepatitis, carrier of Hep B or C, impaired liver function, alcohol liver disease

Answer 24

➢ Dose of drugs metabolized by liver should be decreased (1/2 dose? ) or avoid if possible
➢ MD’s advise needed – lab tests

Question 25

Anesthetic considerations for patient with chronic active hepatitis, carrier of Hep B or C, impaired liver function, alcohol liver disease

Answer 25

One procedure dose of 3 cartridges of 2 % lidocaine is considered relatively limited amount

Question 26

3 complications of liver disease

Answer 26

Abnormal bleeding
Platelet count
Chronic viral hepatitis –> risk of HCC

Question 27

5 manifestations of abnormal bleeding associated with liver disease

Answer 27

• Abnormal synthesis of blood clotting factors
• Abnormal polymerization of fibrin
• Inadequate fibrin stabilization
• Excessive finbrinolysis
• Thrombocytopenia associated with splenomegaly accompanying chronic liver disease

Question 28

3 types of disorders and diseases that are extrahepatic manifestations of liver disease

Answer 28

Immune complex-mediated disease
Autoimmune disorders
Immunological disorders

Question 29

2 immune complex-mediated diseases associated with liver disease

Answer 29

Vasculitis

Polyarteritis nodosa

Question 30

5 autoimmune disorder associated with liver disease

Answer 30

RA
Glomerulonephritis
Thrombocytopenic purpura
Thyroiditis
Pulmonary fibrosis

Question 31

2 immunologic disorders associated with liver disease

Answer 31

• Lichen planus

* Sjogren like syndrome (lymphocytic sialadenitis)

Question 32

13 oral complications of alcoholic liver disease

Answer 32

Poor oral hygiene (caries, gingivitis, periodontitis)
Glossitis
Angular or labial cheilosis
Candidiasis
Oral cancer
Petechiae and ecchymoses
Jaundiced mucosa
Parotid gland enlargement
Alcohol (sweet musty) breath odor
Impaired healing
Bruxism
Dental attrition
Xerostomia