herpes in dentistry

Question 1

implications of hep

Answer 1

• CROSS-INFECTION
• BLEEDING- liver (clotting factors stored and synthesise in the liver)
• ANAESTHESIA/DRUGS- can be metabloosed by the liver

Question 2

common causes of hep

Answer 2

Viral infections
Hepatitis A, B, C
Epstein Barr Virus (glandular fever- can get hep afterwards)
Drug reaction (Paracetamol)

Question 3

paracetamol does

Answer 3

500mg in tablet
4g Maximum / 24hrs
10-15g – acute liver damage
25g invariably fatal

Question 4

uncommon causes of hep

Answer 4

UNCOMMON
Autoimmune

RARE
Wilson’s disease- raised copper,bacuse the liver can’t metabolise or excrete,
Toxins can also cause hepatitis

Question 5

acute hep

Answer 5

Self limiting liver inflammation
Cause - viral, acute alcoholic hepatitis, drugs, toxins, medications
Investigations
LFTs liver functions tests to check hepatic enzymes (hepatic enzymes)
Tests to determine cause – viral serology, immunoglobulins, autoantibody profile.
Liver ultrasonography

Question 6

chronic liver disease

Answer 6

• Clinical features of cirrhosis seen
  (initial compensation)
• Causes include Chronic Hep C and Alcohol abuse

Question 7

signs and symptoms of chronic liver disease

Answer 7

Signs and symptoms due to 
Liver fibrosis
Reduced liver cell mass
Portal hypertension
Reduced liver cell mass problems
Encephalopathy the liver does not detoxify as well leaving problems with the brain
reduced attention span
reverse sleeping pattern
Loss of lean body mass – shoulders
- Accumulation of body water
- Coagulopathy-potiental clotting problems

Question 8

things to note on history

Answer 8

HISTORY
JAUNDICE- deposition of bile salts in the cell (look in sclera of the eyes)
easy brushing
ALCOHOL INTAKE
KNOWN INFECTIONS
HISTORY OF DRUG INTOLERANCE
BLEEDING DISORDERS (other causes)
IVDU- drugs iv
SEXUAL HISTORY

Question 9

clinical signs and symptoms

Answer 9

• jaundice
• easy brushing
• spider naevi(forehead and neck)- central arterial with blood vessels radiating from it - only sen above the chest and can empty and fill
  liver flap- hand flaps when in
• dorsiflexion and resembles a bird flapping wings - this is because liver cannot detoxify ammonia and brain gets irritated
• scratch market - bile salts deep are highly irritating
• sialosis-(non-inflammatory,non-infective & non-neoplastic enlargement of salivary glands)
  -DUPUYTREN’S CONTRACTURE- facia of the plan of the hands contract
  PALMAR ERYTHEMA-palms are red and blotchy as oestrogen metabolises as is not metabolised correctly
  -gynaecomastia- breast tissue in men

Question 10

medication to avoid with liver failure

Answer 10

MICONAZOLE (antifungal)IS CI
FLUCONAZOLE (systemic antifungal) – decreased dose
AVOID ERYTHROMYCIN, METRONIDAZOLE AND TETRACYCLINE
NSAIDS BEST AVOIDED – GI BLEEDING
PARACETAMOL- never!!!
look in BNF

Question 11

things to look out for with alcoholic patients

Answer 11

• RISK OF HAEMATEMESIS(vomiting of blood) due to portal view hypotention
• MANY PATIENTS TAKE PROPHYLACTIC BETA BLOCKERS e.g. PROPRANOLOL
• Reduced plasma clearance of epinephrine
• Unopposed alpha adrenergic effects
• Hypertensive crisis (can stroke)
• Bleeding
• Low platelet count
• Limit to 2 cartilages

Question 12

cross infection - how to prevent

Answer 12

Cross infection
HAND WASHING – HEPATITIS A (feacal), MRSA

AVOIDANCE OF NEEDLESTICK
MASKS, SPECTACLES, GLOVES (double)

Question 13

immunisation - how it works

Answer 13

IMMUNISATION=Hep B

DELTOID INJECTION

• 3 doses
• Initial dose then repeated at 1 & 6 month serology
• Booster – depending on serological markers

Aim for >100 IU/L implies long term immunity

Question 14

LA and GA things to consider

Answer 14

GA- SEVERE JAUNDICE UNDERGOING GA MAY LEAD TO HEPATO-RENAL SYNDROME (renal failure secondary to liver failure) Pt with this are given a certain ga and give water

LA – AMIDE BIOTRANSFORMS IN LIVER
Articaine , Prilocaine better options?
Limit lidocaine to 2 cartridges

SEDATION IN CIRRHOSIS – SPECIALISED UNITS AS SMALL DOSES MAY LEAD TO COMA – BEST AVOIDED

Question 15

Liver function tests (LFT’S)

Answer 15

ALT (Alanine Transaminase)
AST (Aspartate Transaminase) liver cell intergraty

CLOTTING- not a lft but a marker

GAMMA GLUTAMYL TRANSPEPTIDASE (gamma gt) long term excess alcohol and can help differentiate if it is due to alcohol

ALKALINE PHOSPHATASE – 2 types of iso-enzymes need to look at the liver one not the bone one
(in obstructive jaundice – non-specific)

Question 16

serological markers

Answer 16

Hep B surface antigen= 1st manifestation of infection
marker of ongoing infectivity

Anti Hep B s Ag= protection from infection

Hep B c Ag = detected by development of antibody
signifies donor infectivity if Hep B S Ag negative but Hep B c Ag positive

Anti Hep B s Ag and Anti Hep B c Ag signifies previous infection

Hep B e Ag = only found if HB s Ag positive (an index of infectivity)
active viral replication

Question 17

what is encephalopathy -liver related?

Answer 17

Hepatic Encephalopathy, sometimes referred to as portosystemic encephalopathy, is a condition that causes temporary worsening of brain function in people with advanced liver disease. When your liver is damaged it can no longer remove toxic substances from your blood.

Question 18

What to do when bleeding?

Answer 18

• history
• clues
• pre-op FFP