Special Patient Exam 2

What are the functions of the liver?

Detox and filters blood to remove toxins

Major role in metabolism of nutrients

Protein synthesis

Produces bile

Stores nutrients

Blood sugar regulation

Hormone production

Blood clotting

Immune support

Is the liver necessary for survival?

YES

What does liver impairment lead to?

Abnormalities of:

Metabolism of amino acids

Ammonia

Protein

Carbohydrates

Lipids

Significant bleeding may pose a dental problem

Infectious Causes of Hepatitis

Viral hepatitis

Infectious mononucleosis

Secondary syphilis

Tuberculosis

Noninfectious Causes of Hepatitis

Excessive or prolonged use of toxic substances:

Acetaminophen

Alcohol **

Halothane

Ketoconazole

Methyldopa

Methotrexate

What are the five main virus types for viral hepatitis?

1. Hepatitis A (HAV) - infectious hep

2. Hepatitis B (HBV) - serum hep

3. Hepatitis C (HCV) - serum hep

4. Hepatitis D (HDV) - serum hep"delta" occurs with HBV

5. Hepatitis E (HEV) - known as non-A non-B- infectious

Hepatitis A (HAV)

Infectious hepatitis

Replicates in liver, excreted in bile, shed in stool

Fecal contamination of food and water- highly contagious

Found in wells, water supplies, and restaurants (raw shellfish Incubation - 15- 45 days/Mild severity - ~ 2 wks - goes away undiagnosed)

Hepatitis B (HBV)

Serum Hepatitis (persists in blood serum)

Transmission by percutaneous and permucosal exposures(blood and bodily fluids)

Sexual activity

Maternal-infant

Needles

Poor infection control

Contaminated blood transfusions

What is the most common cause of acute hepatitis in the United States?

Hepatitis B

How long can HBV survive in dried blood on environmental surfaces and contaminated needles and instruments

At least 1 week

What is the incubation of HBV?

30-150 days, 75 days most commonly

How do you prevent HBV?

1. Safer sex

2. Vaccination

3. Infection control

Who is most at risk for HBV?

Dental personnel

Health care workers

Refugees

Communal living (prisons, group homes, shelters)

Pts on hemodialysis

IV drug use

Unprotected sexual encounters

Recipients of blood transfusions (lower now)

What is most likely to result in chronic liver damage?

Hepatitis C

Hepatitis C (HCV)

Most common chronic bloodborne infection in US

Similar to HBV in character and behavior

Incubation period 2 wks - 6 mo. (50-day average)

Transmission by blood and blood products

HCV Modes of Transmission

Being born to a mother w/ Hepatitis

Having sex with a person infected with Hep C

Sharing needles, being tattooed or pierced with unsterilized tools that were used on person infected w/ HepC

Getting an accidental needle stick with a needle that was used on a person infected w/Hep C

How can you avoid HCV?

No means of preventing Hep C other than avoiding high-risk behaviors and use of standard precautions

What is is the most significant infectious condition of concern to dental health care professionals?

Hepatitis C

Who is most at risk for HCV

IV drug use- sharing needles

Large percutaneous exposure

Pts on hemodialysis

Multiple sex partners with HCV

Healthcare workers- needle sticks

Infected mother to infant

What is known as the delta virus?

Hepatitis D

Hepatitis D (HDV)

RNA Virus- requires HBV for replication

Occurs in pts. with HBV, either as a co-infection or superinfection

Transmitted parenterally or sexually

Who is most at risk for HDV?

Primarily in IV drug use

Persons with hemophilia

Associated with severe fulminant infections

Greatest risk are chronic carriers of Hep B

What is considered the most severe form of viral hepatitis?

HDV

Hepatitis E (HEV)

Known as Non-A non-B (NANB)

RNA Virus

Similar to HAV - countries w/poor sanitation, such as India, Northern Africa, Mexico, Southeast Asia

Usually, no clear source of exposure can be identified

Transmission - sexual, fecal, oral (e.g., contaminated drinking water)

Incubation - 30-60 days average 35 days

What are the three phases of acute hepatitis?

1. Prodromal phase: abdominal pain, anorexia, nausea, vomiting, fatigue, myalgia, malaise, fever

2. Icterus phase: jaundice

3. Convalescent or Recovery phase: symptoms disappear, but abnormal liver

Medical Management of Hepatitis Viruses

Immunization reduces risk for viral hep.

Vaccines: Twinrix, COMVAX, Harivax, Engerix, Recombivax

Immunity remains effective ~ 10 yrs. or more

Hepatitis Treatment

Palliative & supportive

Bed rest & fluids

Nutritious food

No alcohol

Chronic hep - rarely resolves spontaneously

Treatment is Interferon(IFN) 3 times weekly for 6 mo. - 1 yr.

What medications should the dentist office avoid for patients with viral hepatitis?

Avoid NSAIDS, aspirin, and acetaminophen

Dental Management of Viral Hepatitis

Med. Hx. doesn't always reveal carriers

Treat all with hx. of viral hep. as potentially infectious

Use universal precautions

Dental health care workers: vaccinated

No tx for pts. with active hep

Urgent care (pain) in an isolated operatory

Minimized aerosols

Drugs metabolized in the liver avoided

Excessive bleeding w/ end stage renal disease

Needle stick - Hepatitis B immunoglobulin

Do we treat patients with active viral hepatitis?

NO ELECTIVE TREATMENT (nothing other than urgent treatment)

Oral Manifestations of Viral Hepatitis

abnormal bleeding

increased the risk for hepatocellular carcinoma

Alcoholic Liver Disease (alcoholism)

Chronic addiction to ethanol

Craves and consumes ethanol

Develops tolerance to ethanol's intoxicating effects

Suffers withdrawal when drinking stops

What is the dietary guideline for alcohol conusmption?

Men: 2 drinks or less daily

Women: 1 drink or less daily

What is the pathologic effect of alcohol on the liver?

1. Fatty liver

2. Alcoholic liver disease (a.k.a. alcoholic hepatitis

3. Cirrhosis- most serious and irreversible condition

Non-Alcoholic Fatty Liver Disease

Occurs in about 1 in 5 adults and 1 in 10 children in theU.S.

Obesity is thought to be the most common cause of fatty infiltration of the liver

What does prolonged abuse of alcohol contribute to?

Malnutrition

Blood clotting deficiencies

Anemia

Decreased immune function

Dementia and psychosis

Increased mortality rate in men (> 3 drinks/day)

Alcoholic hepatitis & cirrhosis of the liver

Clinical Presentation of Alcoholism

1. Spider angioma

2. Sialadenosis (enlargement of parotid glands)

Oral Complications of Alcoholism

Very poor OH

Glossitis

Angular or labial cheilosis

Candidiasis

Gingival bleeding

Oral Cancer

Petechiae

Ecchymoses>>>>>

aundiced mucosa

Parotid gland enlargement

Alcohol (sweet musty) breath/odor

Impaired healing

Bruxism>>>>>>

Dental attrition>>>>

Xerostomia

Increased risk for infection

What is the drug interaction pattern of people with alcoholism?

UNPREDICTABLE

Avoid NSAIDS in patients with cirrhosis

can require the use of increased amounts of local anesthetic or additional anxiolytic procedures

Hereditary Hemochromatosis

Too much iron in the blood

Genetically linked

Observe as much as 30% of iron instead of just 10 %

Gastroesophageal Reflux Disease (GERD)

Involves dysfunction of the lower esophageal sphincter

Clinical Features of GERD

Heartburn

Regurgitation

Dysphagia

Chest pain

GERD Etiology

1. Obesity

2. Tobacco

3. Genetic Predisposition

Medical Management of GERD

Lifestyle modifications

Weight management

Tobacco Cessation

Antisecretory drugs (proton pump inhibitors)

Dental Management for GERD

chair positioning to minimize gastric retrograde flow

Drug Considerations:

Acid-blocking drugs decrease the metabolism of some dentally prescribed drugs (antacids)

impair absorption of certain meds

Oral Manifestations of GERD

Dental erosion

Mucosal atrophy/erythema

Dysgeusia

Halitosis

Glossodynia (burning mouth)

Peptic Ulcer

Well-defined break in the GI mucosa resulting from chronic acid or pepsin secretions and destructive effects of and host response to Helicobacter pylori (associated with increasing age)

H. Pylori

Microaerophilic, gram-negative spiral shaped motile bacillus with 4-6 flagella

Produces urease that hydrolyzes urea to ammonia and carbon dioxide

Humans are the only known hosts of H.pylori

Can be found in dental plaque- can serve as a reservoir of infection and reinfect

Associated with peptic ulcers

Fiberoptic endoscopy, biopsy and laboratory testing H. pylori

Treatment: gastric acid inhibitor and antimicrobials

Risk Factors Associated with Peptic Ulcers

Use of NSAIDS, aspirin, amphetamines, corticosteroids, oral bisphosphonates, SSRIs

Age

Psychological and physical stress

Acid hypersecretion

Cigarette smoking

Alcohol

Major comorbid disease

Dental Management for Peptic Ulcers

Identification and risk assessment- review of meds

Avoid aspirin or NSAIDS

Proton pump inhibitors can reduce absorption of certain drugs

Meds can alter taste perception

Check for drug interactions

Chair positioning

Oral hygiene

Observe for fungal infections

Enamel erosion

Xerostomia

Inflammatory Bowl Disease

Inflammation of the bowl

Associated with immune dysfunction with genetic susceptibility

Crohn's Disease

Chronic, progressive, destructive inflammatory disease

Affects any part of the GI tract with "patchy" ulcerations

Higher among Jewish and White

Slightly higher for women

Peak age onset 20- 40 years of age

Occurs most often in people who smoke

Genetic predisposition

Oral Manifestations of Crohn's Disease

Diffuse labial and buccal swelling

Hyperplastic plaques on buccal mucosa with cobblestone appearance

Mucosal tissue tags

Aphthous ulcers (shallow round or oval)

Prevalence of periodontal disease may be higher

Angular cheilitis

Glossitis

Dental Management of Crohn's Disease

Avoid NSAIDS

Encourage tobacco cessation

Palliative care or oral lesions

Ulcerative Colitis

Autoimmune disease (lifelong)

Primarily affects colon

20-30 years of age

Genetic predisposition

Environmental triggers: smoking, alterations in gut microbiome, hormone replacement therapy, oral contraceptives

Associated long-term use/high doses of NSAIDS

Onset may be sudden but, in most cases, chronic

Oral Manifestations of Ulcerative Colitis

Pyostomatitis vegetans

Aphthous ulcers

Gingivitis and periodontal disease

Possible taste changes

Management of Ulcerative Colitis

Palliative care for oral lesions

Avoid NSAIDs

OHI and biofilm removal

General Dental Management of Irritable Bowl Disease

Identification and risk assessment

Elective dental procedures to be scheduled during remission

Adequate pain and anxiety control (corticosteroids can reduce ability to withstand stress but, result in osteopenia)

Avoid aspirin and NSAIDs

Increased risk for lymphoma and infection in individuals taking immunosuppressors

Celiac Disease

Immune mediated disorder involving gluten intolerance resulting in inflammatory injury of the small intestine and reduced absorption of calcium, iron, vitamins ADEK, and folate (genetic predisposition)

Oral Manifestations of Celiac Disease

Aphthous ulcers

Discolored teeth or developmental enamel abnormalities

Angular cheilosis and glossitis (malabsorption of nutrients)

What are the functions of the kidney?

Blood from the aorta reaches the kidneys so it can be filtered and cleaned.

Kidneys remove toxins, metabolic waste, and excess ions from the blood which leaves the body in the form of urine

What are the kidney's responsibilities?

To filter blood to remove wastes and toxins created by normal body activity.

Water and mineral level regulation in the body

Control of the production of red blood cells by putting hormones in the blood

Regulation of blood pressure

How many nephrons do kidneys contain?

1-2 million

Chronic Kidney Disease (CKD)

abnormalities of kidney structure or function, present for 3 months or longer, with implications for health (kidneys are damaged and not working properly)

Progressive kidney disease can result in...

reduced renal function, with effects on multiple organ systems

What does chronic kidney disease eventually result in?

Kidney failure

End-stage Renal Disease (ESRD)

Deterioration of nephrons, kidney failure

What are the common causes of ESRD?

1. Any disease that destroys nephrons

2. Diabetes mellitus

3. Hypertension

4. Systemic lupus erythematosus

5. Hereditary & environmental factors

6. Unknown

Signs and Symptoms of ESRD

Bleeding tendency

Hypertension

Anemia

Intolerance to nephrotoxic drugs metabolized by the kidney

Enhanced susceptibility to infection

Complications of ESRD

1. Tubular malfunction: sodium pump in kidney loses its effectiveness >excretion of sodium occurs

2. Polyuria: excess of urine is excreted

ADVANCED STAGES

3. uremia > death

4. Kidneys cannot handle large intake of sodium > fluid overload, hypertension, risk for cardiac disease

5. Acids accumulate b/c tubular impairment, combination of waste products results in Metabolic acidosis

6. Metabolic acidosis is a disturbance in the body's acid-base balance that results in excessive acidity of the blood

More Complications of ESRD

1. Anemia

2. Leukocyte dysfunction

3. Host defense is compromised

4. Hemorrhagic diathesis -bleed/bruising

5. Cardiovascular system affected

6. Renal osteodystrophy - bone disorders

7. Secondary hyperparathyroidism

8. Hyperpigmentation of skin

End Stage Renal Disease

5th stage of kidney disease (kidney failure)

What are the two treatments for ESRD?

Dialysis (2-3 days)or Kidney transplant

Chronic Kidney Disease Stages

Stage 1: kidney damage with normal kidney function

Stage 2: kidney damage with mild loss of kidney function

Stage 3: mild to moderate loss of kidney function

Stage 4: severe loss of kidney function

Stage 5: kidney failure

Dental Considerations of ESRD

Conservative care

Consult with MD

Screen for bleeding disorders

Closely monitor BP before and during tx

Avoid nephrotoxic meds. (acetaminophen, aspirin, NSAIDS, acyclovir)

Use good surgical technique < risk of bleeding or infection

Use aggressive management of infection

Oral Manifestations of ESRD

Mucosal pallor (pale)

Xerostomia (higher plaque and calc)

Altered taste

Ammonia breath odor

Stomatitis

Palatal petechiae

Oral candidiasis

Bone radiolucencies; loss of lamina dura

Bleeding tendency

Uremic stomatitis: rare condition generally associated with acute renal failure

Dental Considerations for Patients on Dialysis

Same as ESRD

Consider premed: consult with MD•

Arm with shunt: no BP on that arm

Avoid dental tx on day of dialysis (at least 6 hrs but best to treat the day after)

Pre-tx screening for hepatitis virus and HIV advised

Diabetes

Disorder of metabolism due to high glucose levels from the inability to produce and/or use insulin in the pancreas

Insulin

hormone needed to convert sugar (glucose), starches, and other foods into the energy needed for daily life

Persistent hyperglycemia can lead to...

metabolic and vascular complications

Insulin functions to reduce the concentration of glucose in the blood by...

1. Stimulates the muscles to remove more glucose from the blood

2. Stimulate both the muscles and the liver to convert more glucose into glycogen for storage

3. To inhibit the liver from producing glucose from glycogen or other stored materials

4. Stimulate the muscles and liver to oxidize carbohydrates quickly

Type I Diabetes

Body cannot produce insulin (children and young adults) with an unknown cause

What does type I diabetes result from?

The destruction of pancreatic beta cells causing the pancreas to produce little or no insulin

The body is unable to use glucose for energy > glucose then accumulates in the blood > hyperglycemia and diabetes

Type II Diabetes

Either the body does not produce enough insulin, or the cells do not use the insulin correctly

What is the most common form of diabetes most commonly caused by lifestyle factors?

Type II

What are the primary factors in type II diabetes?

Obesity and lack of activity

Type II Diabetes Risk Factors

1. High blood pressure

2. Smoking

3. Sedentary lifestyle

4. Overweight

5. High fat and cholesterol levels

WHAT ARE THE THREE P'S OF DIABETES

1. Polyuria

2. Polydipsia

3. Polyphagia

Healthy Pancreas

Excretes insulin into the bloodstream which enables uptake by body cells

Without insulin production by the pancreas, glucose accumulates in the blood, resulting in hyperglycemia (normal blood glucose levels range from 60-150mg./dL)

Gestational Diabetes Mellitus (GDM)

any degree of glucose intolerance with the onset or first recognition during pregnancy

How does GDM effect the fetus?

infants are larger, may be premature, may see congenital malformations, perinatal death high, tend to develop type II later in life

Fasting Plasma Glucose (FPG)

Normal: Less than 100 mg/dl

Prediabetes: 100 mg/dl to 125 mg/dl

Diabetes: 126 mg/dl or higher

Oral Glucose Tolerance Test (OGTT)

Normal: Less than 140 mg/dl

Prediabetes: 140 mg/dl to 199 mg/dl

Diabetes: 200 mg/dl or higher

HbA1C

Under 5.7: Non-diabetic

Between 5.7 and 6.4: Prediabetes

Between 6.0 and 6.9: Controlled diabetes

Between 7.0 and 8.9: Uncontrolled diabetes

Over 9.0: Critically high

Which test has limited value in diabetic testing?

Urinary glucose and acetone

What is the treatment for type I diabetes?

diet, physical activity, insulin

What is the treatment for type II diabetes?

diet, physical activity, insulin, oral hypoglycemic agents (OHA)

Complications of Diabetes

Difficult to fight infections; poor wound healing

Atherosclerosis

Retinopathy

End-stage renal disease

Diabetic neuropathy

Skin rashes; deposits of fat in skin

What is the severity of diabetes symptoms largely dependent on?

Level of glycemic control

Diabetes Medical Management

Not curable- requires strict glycemic control

Modified healthy nutrient intake and weight reduction

Physical activity

Blood pressure control

A favorable lipid profile

If standard therapies fail, pancreas and kidney transplants