3. Gastrointestinal System

6. Gastrointestinal Disease

11. Intestinal Malabsorption

12. Inflammatory Bowel Disease Ulcerative Colitis Regional Enteritis (Crohn’s Disease)

13. Hepatobiliary Disease

17. Liver Functions Synthesis Billirubin Protein –Globulins –Albumin –Prothrombin –Clotting Factors

18. Liver Functions Metabolism –Proteins –Carbohydrates –Lipids Biochemical Functions –Coagulation –Drug Metabolism

19. Liver Disease Bleeding Disorders Digestive Problems Infections Metabolic Disorders Altered Drug Metabolism

20. MEDICAL HISTORY Hepatitis Liver Disease Jaundice Hospitalization Transfusion Alcohol

21. Hepatic Disease Viral Hepatitis Cirrhosis

22. Liver Disease (Etiologic Factors) Toxins (alcohol, drugs) Infectious (viruses, bacteria, parasite) Bile Excretion Disturbance Tumors (Primary, Metastatic)

23. Cirrhosis (liver fibrosis) Laennec’s (Alcoholic) Biliary Post-Necrotic

24. HEPATOTOXINS

25. Hepatotoxins Chloroform Carbon Tetrachloride Phosphorous Mushrooms Drugs

27. Alcoholism

29. Findings Jaundice Facial Erythema Spider Telangiectasia Parotid Enlargement

30. ICTERUS (Jaundice) Hyperbilirubinemia >2.5 mgm/100 ml Normal < 1 mgm/100 ml

33. Alcoholism (Oral Complications) Poor oral hygiene Periodontal disease Xerostomia Caries Altered drug metabolism Hemorrhage

34. Alcoholic Liver Disease (Lannec’s Cirrhosis) Bleeding Tendencies Drug Metabolism

35. Laboratory Tests (Liver Function) AST – (SGPT) ALT – (SGOT) Billirubin – (CB, UCB) LDH ALK PHOS

36. Acquired Hypoprothrombinemias

37. Vitamin K (Fat Soluble) & Intestinal Flora Liver Prothrombin

38. Dental Management of the Liver Failure Patient

39. Dental Management of Patient with Alcoholic Liver Disease 1.Detection by a. History b. Clinical examination c. Repeated odor on breath d. Information from family members or friends 2.Referral or consultation with a physician to a. Verify history b. Check current status c. Check medications d. Check laboratory viruses e. Obtain suggestions for management

40. Dental Management of Patient with Alcoholic Liver Disease (cont.) 3.Laboratory screening (if otherwise not available from physician) a. CBC with differential b. AST, ALT c. Bleeding time d. Thrombin time 4.Minimize drugs metabolized by liver

41. Dental Management of Patient with Alcoholic Liver Disease (cont.) 5.If screening tests abnormal, for surgical procedure consider using a. Antifibrinolytic agents b. Fresh frozen plasma c. Vitamin K d. Platelets

42. Common Dental Drugs Metabolized Primarily by the Liver Local Anesthetics Lidocaine (Xylocaine) Mepivacaine (Carbocaine) Analgesics Acetaminophen (Tylenox, Datril) Acelysalicylic acid (aspirin) Codeine Meperidine (Demerol)

43. Common Dental Drugs Metabolized Primarily by Liver (cont.) Sedatives –Diazapam (Valium) –Barbiturates Chlordiazepoxide Antibiotics –Ampicillin –Tetracycline

44. Hepatitis (Inflammation of the liver)

46. Hepatitis (Inflammation of the Liver) Primary –Viral –Drug Infected –Toxic Secondary –Mono –Syphilis (2 °) –TB

47. VIRAL HEPATITIS

48. Viral Hepatitis A – HAV B – HBV C – Non-A, Non-B (Transfusion Related) D – HDV (Delta) E – Non-A, Non-B (Enteric Related)

49. Symptoms of Acute Hepatitis Prejaundiced phase –Loss of appetite, nausea, vomiting, headache, fever, muscle soreness Jaundiced phase –Yellow eyes, white or grey stools, brownish urine

50. Clinical Stages - Hepatitis Incubation Prodromal Ictal

51. JAUNDICE (Ictal stage)

52. Ictal phase Hepatomegaly RUQ tenderness Dark urine Grey stools Jaundice

55. Hepatitis A

56. Hides in RNA Infectious/short incubation Fecal-oral 2-6 weeks Rare sequelae No carriers

57. DELTA AGENT

58. Delta Hepatitis (HDD) Variant form Only active if HB S Ag Present Drug abusers more susceptible More severe diseases HB vaccine is effective

59. Non-A, Non-B Hepatitis Post Transfusion (HCV) Enterically Transmitted (HEV)

60. Non A – Non B Hepatitis Bloodborne (C) –Body fluids –carrier Epidemic (E) –Oro-fecal –No carrier

61. Hepatitis C (HCV) (Non A – Non B)

62. Hepatitis C Virus 35,000 – 180,000 Infections/yr. In US 3,000 – 54,000 symptomatic (30%) > 85% chronic infection 24,500 – 126,000 chronic liver disease/yr. 8,000 – 10,000 deaths/yr. Source: CDC

63. HEPATITIS B AND THE HEALTH-CARE PROFESSIONAL

64. Hepatitis B Virus 140,000 – 320,000 infections/yr. in U.S. 70,000 – 160,000 symptomatic 8,400 – 19,000 hospitalizations 5,000 – 6,000 deaths in a year. Source: CDC

65. HBV Infections (HCW) 1983- 17,000/yr (386/100,000) 1995- 400 (9.1/100,000) General Population 50/100.000

66. Hepatitis B Infections USA-3% Endemic Areas-10-25% –Southeast Asia –Sub-Sahara Africa

69. Dental Management of the Hepatitis B Carrier

70. The Hepatitis-B Vaccine

73. Antibody Testing (HCW) Post-Immunization 30-60 days CDC 1998

74. Responder with 10 SRU or less (BOOSTER?)

75. PRECAUTIONS (Hepatitis B Patient) ???

76. Emergency Dental Care for Patient with Hepatitis Consult with patient’s physician to discuss patient’s status and planned dental treatment. If surgery is necessary, obtain preoperative prothrombin time and bleeding time, discuss abnormal results with physician

77. END-STAGE LIVER DISEASE

78. LIVER DISEASE End Stage LIVER TRANSPLANT

79. Liver Transplant

80. The End

84. Medical History

86. LABORATORY TESTS

87. NON-A, NON-B HEPATITIS