This document discusses hepatitis and liver cirrhosis. It defines hepatitis as inflammation of the liver that can result from drugs, poisons, or infections. The main causes of hepatitis are viral strains A-E and G, bacteria, alcohol, drugs, and autoimmune disorders. Chronic liver disease includes chronic hepatitis and cirrhosis. Cirrhosis occurs when liver tissue is damaged and replaced by scar tissue, which can lead to life-threatening complications like bleeding and organ failure. The document provides details on each type of viral hepatitis and guidelines for safely treating dental patients with liver disease or hepatitis to prevent further infection.

1. Hepatitis and liver cirrhosis
DR.WAFA IRSHAIDAT
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2.  Patients with liver disorders are of significant interest to the dentist, because
liver plays a vital role in metabolic function ,including the secretion of bile
needed to fat absorption, conversion of sugar to glycogen, excretion of bilirubin.
 Many biochemical function performed by the liver , such as synthesis of
coagulation factors and drug metabolism, may be adversely affected.
 Chronic liver disease include :chronic hepatitis and liver cirrhosis
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3. Hepatitis:
Is inflammation of the liver, which result from drugs, poison and infection.
 causes of Hepatitis:
1. Viral Hepatitis( A,B,C,D,E and G)
2. Bacterial( secondary syphilis, TB)
3. Alcoholic Hepatitis
3. Drug induced Hepatitis
4. Autoimmune Hepatitis
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4. Hepatitis A (infectious)
 Common in childhood
 Spread of hepatitis a is largely faeco-orally through consumption of contaminated water or food.
 Through close person to person contact
 Can be transmitted sexually and through body fluid.
 Incubation period is 2-6 weeks Recovery is usually uneventful
 There is no evidence of either a carrier state or progression to chronic liver disease.
 Hepatitis A gives long lasting immunity
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5.  Diagnosis: by demonstrating serum antibody to the HAV
 Hepatitis A vaccine is available
 Dental aspect: no risk of transmission of Hepatitis A during
dentistry conducted properly
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Hepatitis A (infectious)

6. Hepatitis B (serum)
 A serious disease caused by HBV
 Cause lifelong infection, cirrhosis, liver cancer , liver failure,
fuliminat hepatitis and death
 Transmitted by: parenteral( by unsecured blood products,
intravenous drugs abuse and tattoo) , sexually and prenatally.
 HBV is a robust virus, survives for a week or more in dried blood on
surface. So can be transmitted to patients and staff in health care
facilities easily.
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7.  Incubation period is 2-6 months
 Complications of hepatitis B indicate a carrier state , chronic infection, cirrhosis,
liver cancer, polyarthritis nodosa or death.
 Serum enzyme estimation are useful in the diagnosis of hepatitis
AST ( aspartate transaminase ) and ALT ( alanine transaminase ) are raise in
proportion to the severity of acute hepatitis.
 Alkaline phosphatase, Alpha fetoprotein and Serum bilirubin levels are also raise.
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Hepatitis B (serum)

8. High-risk groups for Hepatitis B
 -Patients who received blood transfusion .
 -Patients who receiving hemodialysis for end-stage renal disease .
 -Immunocompromised patients.
 -Health care workers .
 -Intravenous drugs abusers.
 -sexually active individuals, who don’t practice safe sex
 -patients from Developing word.
 -tattooing and acupuncture .
 Newborn whose mother is infected with hepatitis B.
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9. Dental aspects:
• Some drugs should be used with caution
Type of drug Drugs contraindicated Alternative to use
Analgesics Aspirin, codeine, NSAID, opioids,
Meperidine, indomethacin
Paracetamol, oxycodone
Antimicrobials Aminoglycosides, azithromycin,
erythromycin estolate, clarithromycin,
clindamycin, doxycycline,
tetracycline, minocycline,
flucloxacillin, metronidazole, azole
antifungals
Amoxicillin, ampicillin, cephalosporins,
nystatin, fluconazole, erythromycin
stearate
corticosteroids prednisone prednisolone
antidepressants MAO inhibitors, SSSRIs
Muscle relaxants suxamethonium Atracurim, cisatracurium
Local anesthetics lidocaine Priocaine, articaine
General anesthetics Halothane, thiopental Desoflurane, isoflurane, sevoflurane
anticonvulsants Carbamazepine, phenytoin
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10. Dental aspects
 Patients with normal platelets count and normal prothrombin time
and INR can be undergo dental treatment safely.
 The main danger for infection is from needle stick injuries, some
25% may transmit HBV infection.
 Needle stick injuries involving HBV can transmit the virus, post
exposure prophylaxis (PEP) with HBIG and /or hepatitis B vaccine
series within 24 hours of contact after evaluation of the HBsAg
status.
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11. Hepatitis B vaccination:
 The hepatitis B vaccine is a recombinant vaccine of HBsAg.
 usually 2-3 vaccine is given, the 2nd injection at least one month after the 1st Dose and the 3rd
injection being administrated 6 months after the 1st Dose.
 After vaccination anti-HBs develops and confer 90% protection many years and possibly for
life, but may not protect against pre-core variant.
 Boosters recommended at 5 years interval.
 Post-vaccination testing recommended for:
-Immunocompromised patients.
-Person who received vaccine in the buttock
-An infant born to HBsAg positive mother.
-Health care workers who have contact with blood.
-Sex partner with Hepatitis B infection.
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12. Hepatitis C
 Most common in intravenous drugs abusers and blood transfusions
 Similar incubation period to hepatitis B .
 less severe clinically than hepatitis B
 Most cases develop to chronic cases or liver cancer( the link between hepatitis
C and carcinoma more than hepatitis B)
 Might be co-infected with hepatitis G or B
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13.  Diagnosis by detection of HCV RNA and anti HCV antibody in the blood
 50% of acute cases resolve spontaneously
 There is no vaccine against hepatitis C
Hepatitis C
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14. Dental aspects
 Hepatitis C can be transmitted through needle stick injuries (10%)
 May be associated with oral features-sicca (sjogren) syndrome, non-Hodgkin
lymphoma and lichen planus.
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15. Hepatitis D
 Incomplete virus carried by HBV
 Always co-infected with hepatitis B
 Vaccination against HBV protects indirectly against HDV
 Dental aspects: the same considerations apply as for hepatitis B
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16. Hepatitis G
 Co-infected with hepatitis C or B
 Less severe than hepatitis C but it is followed by persistent infection
 HGV is not known to be transmitted during dentistry
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17. Hepatitis E
 Acute and self limiting infection
 Transmitted faeco-orally
 Incubation periods 2-9 weeks
 Dental aspects: the same as Hepatitis A
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18. Guidelines for dental treatment of hepatitis
patients
 No dental treatment other than urgent care should be rendered for
patient with acute viral hepatitis.
 Hepatitis B is of primary concern to the dentist, individuals carry the
virus up to 3 months after the symptoms have disappeared , so any
patient with a recent history of Hepatitis B should be treated for dental
emergency only.
 For recovered HAV or HEV perform routine periodontal care.
 For recovered HBV and HDV consult with the physician and order
HBsAg and HBs laboratory tests.
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19.  If bleeding is likely during or after treatment , measure Prothrombin time (PT) and
Bleeding time.
 All personnel in clinical contact with the patient should be full barrier technique (
mask, gloves, glasses or eye shield and disposable gowns)
 Minimize aerosol production by not using ultrasonic instrumentation, air syringe or
high speed handpieces.
 Rinse with chlorohexidine mouth wash 30 seconds before the procedures, to
minimize the concentration of virus in the saliva
Guidelines for dental treatment of
hepatitis patients
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20. PREVENTION OF VIRAL HEPATITIS
• Always following routine barrier precautions and safely handling needles and
other sharps.
• Drug addicts never sharing needles, syringes, or water for injection
• Not sharing personal care items that might have blood on them ( razors,
toothbrushes).
• Avoiding having a tattoo or body piercing, unless the piercer follows strict
health practice.
• Not donating blood, organs if HBV or HCV positive.
• Not inhaling cocaine through contaminated straws.
• Vaccine is recommended for all Health care workers and high-risk groups.
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21. Alcoholic Hepatitis
 Alcohol injures the liver by blocking the metabolism of Protein, Fats
and Carbohydrates.
 The amount of alcohol that can injures the liver varies greatly from
person to person .
 Exposure to alcohol over long periods may causes liver fibrosis –
cirrhosis –liver failure.
 Non-alcoholic hepatitis: the same as alcoholic one but caused by
obesity, protein malnutrition, coronary artery disease or
corticosteroid treatment.
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22. Drug-Induced Hepatitis
Drugs and chemically related to liver
damage
Dose-related liver damage Non-dose related liver damage
Acetaminophen( paracetamol) Antithyroid drugs
alcohol Erythromycin estolate
Anabolic steroids flucloxacillin
isoniazid halothane
ketoconazole nitrofurantoin
methyldopa phenylbutazone
Methyl testosterone phenytoin
tetracycline sulfonamides
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23. Dental aspects
 Aspirin ingestion by children during viral infection might causes
Reye syndrome
 Reye syndrome: liver damage with encephalopathy and abnormal
accumulation of fat in the liver with severe rise in intracranial
pressure.
 So Aspirin is contraindicated for children under 16, Paracetamol is
the preferred analgesic for them.
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24. Autoimmune Hepatitis:
 -Most common in young women.
 -Can include acne, arthralgia, amenorrhea , hemolytic anemia , nephritis ,
thyroiditis and ulcerative colitis.
 -Often progress to cirrhosis.
 -Autoimmune Hepatitis is typically response to immuno-suppressant drugs.
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25. Cirrhosis of the liver
 Cirrhosis: is inflammation and necrosis of liver’s cells followed by
replacement of normal functioning liver with fibrotic tissues.
 Cirrhosis is a potentially fatal disorder.
***Obstruction to the portal circulation lead to portal hypertension,
esophageal varices, and hematemesis, which cause anemia.
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26. Clinical features of cirrhosis
 Jaundice
 Oedema, ascites
 Gastrointestinal hemorrhage
 Mental confusion
 Hepatomegaly, splenomegaly
 Finger clubbing, opaque nails
 Spider naevi
 Sparse hair
Other manifestations
Sialosis,
Bleeding( liver failure)
Portal hypertension and varices
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27. Dental aspects of liver disease:
 Patients can present with serious bleeding problems, so PT is needed
 There may be a risk from transmission of infection
 Impaired Drug metabolism causes central nervous system depressants, such as
sedatives, analgesics and general anesthesia.
 The maximum safe dose of local anesthesia is lower than in healthy person ( esp.
Amide type), Prilocaine and Articaine are preferred to Lidocaine.
 The Hepatologist should be consulted if surgery is needed.
 Aspirin and other NSAIDs should be avoided because of the risk of Gastric
Hemorrhage .
 Analgesia is best achieved with Acetaminophen.
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28.  If a jaundiced patients must undergo major surgery, aggressive treatment with
intravenous fluids and diuresis with mannitol are indicated to avoid acute renal
failure.
 Spontaneous bacterial peritonitis is a potential problem in cirrhosis with ascites.
Dental aspects of liver disease
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