HOSPI LAB

HEPATITIS - Caused by the hepatitis A virus (HAV) from

- A broad term that means inflammation of liver Picornaveridae family
HAV is transmitted through
LIVER - Fecal-oral route
- 2nd largest organ in the human body - Close person-to-person contact with an infected
- Largest gland in the human body person
- Sexual contact with an infected person
ANATOMY - Ingestion of contaminated food or water
- It lies under the diaphragm in the right upper Incubation period:
abdomen and mid-abdomen and extends to the left - 15-50 days
upper abdomen - Average of 28 days
- The liver has the general shape of a prism or wedge, Likelihood of symptomatic acute infection:
with its base to the right and its apex to the left - <30% of children <6 years of age have symptoms
- >70% of older children and adults have jaundice
FUNCTIONS Treatment
- Holds 13% of the body’s blood supply - No medication available
- Production of bile - Best addressed through supportive treatment
- Detoxifies chemicals
- Metabolizes drugs
- Makes proteins important for blood clotting and other
functions HEPATITIS B
- Caused by the hepatitis B virus (HBV) from
ETIOLOGY Hepadnaveridae family
- Viral hepatitis HBV is transmitted through
- Alcoholic hepatitis - Percutaneous, mucosal, or non-intact skin exposure
- Autoimmune hepatitis to infectious blood, semen, and other body fluids
- Non-alcoholic steatohepatitis (NASH) Incubation period:
- 60-150 days
TYPES OF VIRAL HEPATITIS - Average of 90 days
SOURCE OF ROUTE OF
CHRONIC Likelihood of symptomatic acute infection:
INFECTIO PREVENTION - Most children <5 years of age do not have symptoms
VIRUS TRANSMISSION
N
- 30-50% of people > 5 years of age develop symptoms
- Pre-post Chronic infection develops in:
A - Feces - Feco-oral - No exposure
- Immunization - 90% of infants after acute infection at birth
- 25-50% of children newly infected at ages 1-5 years
- Blood - Pre-post
exposure - 5% of people newly infected as adults
- Blood - Percutaneous Treatment
B - Yes - Immunization
derived - Permucosal - For acute infection
- Body fluids - Blood donor
screening o No medication available
- Blood o Best addressed through supportive treatment
- Blood - Percutaneous - Blood donor - For chronic infection
C - Yes
derived - Permucosal screening
o Regular monitoring for signs of liver disease
- Body fluids
progression
- Blood o Use of antiviral drugs
- Percutaneous - Pre-post
D - Blood - Yes exposure
derived - Permucosal - Immunization
- Body fluids
- Ensure safe
HEPATITIS C
E - Feces - Feco-oral - No - Caused by the hepatitis C virus (HCV) from
drinking water
Flaviveridae family
Other viruses that cause hepatitis HCV is transmitted through
- Cytomegalovirus - Direct percutaneous exposure to infectious blood.
- Herpes virus Mucous membrane exposures to blood
- Rubella virus - Sharing contaminated needles, syringes, or other
- Epstein-barr virus equipment to inject drugs
Incubation period
HEPATITIS A - 14-182 days
- Average of 84 days
 HOSPI LAB

Likelihood of symptomatic acute infection: - Symptoms of all types of viral hepatitis are similar
- Jaundice might occur in 20-30% of people and can include one or more of the following:
- Nonspecific symptoms (e.g., anorexia, malaise, or o Jaundice
abdominal pain) might be present in 10-20% of o Fatigue
people o Fever
Chronic infection develops in: o Nausea
- Over 50% of newly infected people o Vomiting
Treatment o Abdominal pain
- For acute infection
o Joint pain
o AASLD/IDSA recommend treatment of
o Dark urine
acute HCV without a waiting period
o Clay-colored stool
o Pegylated interferon
o Diarrhea (HAV only)
- For chronic infection
o 8-12 weeks of oral therapy
BIOMARKERS (diagnostic markers)
o Pegylated interferon
- Biological parameters that aid the diagnosis of
o Ribavirin rebetol
diseases
o Protease inhibitors
Antigens
HEPATITIS D - Substances or toxins in your blood that trigger your
- Caused by the hepatitis D virus (HDV) from body to fight them
Deltavirus genus. - Two types
- A defective virus. Cannot replicate on its own o Heteroantigens – foreign bodies
- Only people infected with Hepatitis B can contract o Autoantigens – self-antigens
Hepatitis D
- Transmission is same with Hepatitis B
Antibodies
- Can be acute or chronic
- Kills antigens, stops infection
- HDV-HBV co-infection is considered the most
- Different types of antibodies
severe form of chronic viral hepatitis due to more
o IgG
rapid progression towards liver-related death and
o IgM
hepatocellular carcinoma
o IgA
Incubation period
- 2-12 weeks o IgE
Treatment o IgD
- Pegylated interferon alpha for at least 48 weeks
Hepatitis A
HEPATITIS E - For acute infection:
- Caused by the hepatitis B virus (HBV) from o IgM anti HAV
Hepeveridae family Hepatitis B
- Discovered in 1980 (Dr. Mikhall Balayan) - For acute infection:
- HEV transmission is same with HAV o HBsAg
- Water –borne disease o IgM anti-HBc
- Acute infection only - For Chronic infection:
- Reported mainly in young adults – 14-45 y/o o HBsAg
- HEV in pregnant women can induce a fulminating o Anti-HBs
form of acute disease. It can cause intra-uterine o Total anti-HBc
death, abortions, and high perinatal morbidity and Hepatitis C
mortality - For Chronic infection:
Incubation period o Assay for anti-HCV
- 2-9weeks o Qualitative and quantitative nucleic acid
- Average of 40 days tests (NAT)
Treatment Hepatitis D
- No specific treatment - High levels of:
- Best addressed through supportive treatment o IgG anti-HDV
- Recovery is always complete o IgM anti-HDV
- No vaccine available
- Confirmed detection of HDV RNA in serum
SYMPTOMS
Hepatitis E
 HOSPI LAB

- High levels of:

o IgG anti-HEV
o IgM anti-HEV
- Confirmed detection of HEV RNA in serum

ORAL COMPLICATIONS
- Potential for abnormal bleeding in cases of
significant liver damage
- Check bleeding parameters such as PT (prothrombin
time). If >28 seconds, may have bleeding
complications. Bleeding time should ideally be
<7min

DENTAL MANAGEMENT
1. Identify undiagnosed individuals
2. Patients with active hepatitis
- No treatment other than urgent care
- Contact physician immediately
3. Patient with history of Hepatitis
- Identify carriers
- Universal precaution for all patients
- Inoculation of all dental personnel with
Hepa vaccine
4. Patients that are hepatitis carriers
- Some may have chronic acute hepatitis
leading to compromised liver function and
interfere with hemostasis and drug
metabolism
- Consult physician
5. Patients with signs and symptoms of hepatitis
- Do not treat electively
- Refer to physician immediately

TREATMENT MODIFICATION
- Completely recovered individuals: NO
TREATMENT MODIFICATION REQUIRED
- Chronic active hepatitis/Carriers of HBsAg and has
impaired liver function: drugs metabolized by the
liver should be avoided if possible. If not, decrease
dose
 HOSPI LAB
HYPERTENSION
- Hypertension is persistently raised blood pressure
resulting from increased peripheral vascular
resistance
- In adults, a sustained diastolic blood pressure of
90mmHg or greater and a sustained systolic blood
pressure of 140mmHg or greater are abnormal
- Dental management can be complicated since any
procedure causing stress can further increase blood
pressure and can precipitate acute complications such
as cardiac arrest, or cerebrovascular accident
- Chronic complications of hypertension such as
impaired renal function can affect dental
management
Normal blood pressure
- <120/80 mmHg
Elevated blood pressure
- Systolic pressure ranging from 120-129mmHg and a
diastolic pressure below (not above 80 mmHg
Stage 1 hypertension
- Systolic pressure ranging from 130-139 mmHg or a
diastolic pressure ranging from 80-89 mmHg
Stage 2 hypertension
- Systolic pressure of 140 mmHg or higher or a
diastolic pressure of 90 mmHg or higher
Hypertensive crisis
- >180/120mmHg
ORAL MANIFESTATIONS
Xerostomia
- Caused by diuretics
- May have sequela of decay, difficulty in chewing,
swallong, and speaking, candidiasis, and oral burning
syndrome
- Treat with parasympathetic agents such as
pilocarpine
Gingival hyperplasia
- Caused by calcium channel blockers
- Majority are associated with nifedipine
- Manifested by pain, gingival bleeding, and difficulty
in mastication
Lichenoid reaction
- Associated with diuretics, methyldope, propranolol,
captopril, and many antihypertensives
- If medication could not be changed, lichenoid
reactions are treated with topical corticosteroids
Ageusia and Dysgeusia
- Ageusia – loss of taste
- Dysgeusia – alteration of taste
- Caused by beta blockers, acetazolamide, and
diltiazem
- Dysgeusia may result through a mechanism affecting
salivary handling of metal ions such as magnesium
Facial Nerve Paralysis
- Because of edema or hemorrhage in the facial canal
- Usually seen in patients with malignant hypertension
- Characterized by the sustained increase in systolic
blood pressure >200 mmHg and/or sustained increase
in diastolic blood pressure >120 mmHg
Periodontitis
- Inflammation represents a cornerstone of
cardiovascular disease
- Low-grade bacteremia and endotoxemia,
accumulation compounds formed under oxidative
stress, as well as cross-reactivity or molecular
mimicry between bacterial and self-antigens, have
also been regarded as additional mechanisms
potentially linking periodontal disease to systemic
diseases.
Gingival bleeding
- One of the common clinical features seen in
hypertensive patients
- In most cases of arterial hypertension the gingival
mucous was characterized by widening of lymphatic
vessels and interstitial spaces
DENTAL MANAGEMENT
Local anesthetic
- Local anesthetics are recommended for patients with
hypertension because they can decrease pain and
increase comfort
- The selection of a local anesthetic: duration of the
procedure, the need for hemostasis, the required
degree of pain control
- Vasoconstrictors added to local anesthetics to aid in
hemostatic control and to increase the duration
- Risk of epinephrine: sympathomimetic effect on
cardiac B1-receptors.
- Avoid norepinephrine or levonordefrin, unopposed
activation of a1-receptors in HT increase the duration
of the drug’s effect 2% lidocaine with 1:100,000
epinephrine most commonly used to achieve the
necessary degree of anesthesia for most dental
situations
- Maximum recommended dose of local anesthetic
solution for hypertension (poorly controlled): two
1.8-ml cartridges (total dose of 3.6 ml) with
1:100,000 (0.036mg) epinephrine per appointment
CONTRAINDICATION FOR ANESTHETIC WITH
VASOCONSTRICTOR
- Include severe uncontrolled hypertension
- Caution when administering local anesthetics at
dosages higher than recommended
- Should also be aware of the potential interactions
between commonly used local anesthetics and
antihypertensive drugs
- Lengthy procedures are anticipated, the epinephrine
should be diluted to a ratio of 1:200,000
- Apprehensive, sweating, or nervous patient likely has
increased levels of endogenous epinephrine
 HOSPI LAB

- Administration of epinephrine to the nervous or

apprehensive stage 2 patient would be
contraindicated

POTENTIAL DENTAL CARE PROBLEM

- Stress and anxiety may cause increase in BP
- Treated with antihypertensive agents may become
nauseated or hypotensive, or may develop orthostatic
hypotension
- Excessive use of vasopressors may cause significant
elevation of blood pressure
- Sedative medication may bring about hypotensive
episode

MANAGEMENT
- Reduce stress and anxiety by premedication, short
appointments, avoid hypoxia
- If overly stressed, terminate appointment
- Avoid orthostatic hypotension
- Avoid stimulating gag reflex
- Select sedative medication and dosage cautiously

DRUG CONSIDERATIONS
- Minimal concentration (epinephrine 0.036mg),
aspirate before injection and inject slowly
- Caution when using vasoconstrictors in patient taking
a nonselective beta-blocker
- Do not use gingival packing material that contains
epinephrine
- Reduce dosage of barbiturates and other sedative
(action may enhance by antihypertensive agent)
- Epinephrine used judiciously with MAO inhibitor

MEDICATION RELATED TO DENTAL PRACTICE

- Alpha Blockers
- Angiotensin II Receptor Blockers
- Beta-Blockers
- Diuretics
- ACE Inhibitors
- Calcium Channel Blockers
- Beta Adrenergic Blockers
- Vasodilators
 HOSPI LAB
HYPERTENSION CANVAS
M6 - Lesson 1: Oral Manifestations of Hypertension
According to a dental continuing course on Management of
Patients with Chronic Diseases by Melanie Simmer-Beck
published in dentalcare.com,
“There are no oral manifestations that are the direct result of
hypertension. Medications used to treat hypertension may
produce xerostomia, lichenoid mucosal lesions, burning
mouth, delayed healing, and gingival bleeding. Gingival
hyperplasia may be present in patients who are taking a
calcium channel blocker. Oral lesions may be present in
patients who have an allergic reaction to mercurial diuretics.”
Oral Manifestations Caused by the Adverse Effects of
Antihypertensive Drugs
1. Xerostomia
Many antihypertensives medications like ACEIs,
thiazide diuretics, loop diuretics, and clonidine are associated
with xerostomia. Its likelihood increases with the number of
concomitant medications. Xerostomia has many
consequences, like decay, difficulty in chewing, swallowing,
and speaking, candidiasis, and oral burning syndrome.
Sometimes the feeling is transient and salivary function is
adjusted by the patient itself. There are situations when is
required to change the antihypertensive medication. It is often
necessary to treat xerostomia directly with
parasympathomimetic agents such as pilocarpine or
cevimeline. Other recommendations include frequent sipping
of water, sugarless candies, coffee consumption reduction, and
avoiding alcohol containing mouthwashes. To reduce the risk
of caries topical applications of fluoride, particularly in the
form of gels with high concentrations applied by brush or
trays, are recommended.
2. Gingival Hyperplasia
It can be caused by calcium channel blockers, with an
incidence ranging from 6 to 83%. The majority of cases are
associated with nifedipine. The effect could be dose related.
Gingival hyperplasia is manifested by pain, gingival bleeding,
and difficulty in mastication. A good oral hygiene greatly
reduces its incidence. By changing antihypertensive
medication hyperplasia can be reversed.
3. Lichenoid Reaction
Many antihypertensives (thiazide diuretics,
methyldopa, propranolol, captopril, furosemide,
spironolactone, and labetalol) are associated with oral
lichenoid reactions. Clinical forms differ greatly from lichen
planus itself. The easiest way to treat it is to change
antihypertensive medication, and lichenoid reactions are
resolving after discontinuation of the responsible drug. If
medication could not be changed, lichenoid reactions are
treated with topical corticosteroids.
4. Other Undesirable Effects
ACE inhibitors are associated with cough and loss of
taste (ageusia) or taste alteration (dysgeusia). Dysgeusia has
also been reported with other antihypertensives use, like β-
blockers, acetazolamide, and diltiazem. It has been postulated
that dysgeusia may result through a mechanism affecting
salivary handling of metal ions such as magnesium.
5. Facial nerve paralysis
Facial nerve paralysis in hypertension is because of
edema or hemorrhage in the facial canal, but the exact etiology
is unknown. Usually facial nerve paralysis is seen in patients
with malignant hypertension. It is characterized by the
sustained increase in systolic blood pressure ≥ 200 mm HG
and/or sustained increase in diastolic blood pressure ≥ 120 mm
HG. But it is more significant in patients with increased
diastolic blood pressure rather than increase in systolic blood
pressure.
6. Gingival enlargement
Is also one of the most common clinical finding in
patients with hypertension taking anti-hypertensive medication
especially calcium channel blockers. Gingival enlargements
appear clinically as firm nodules of gingival overgrowth seen
on either buccal or facial aspects and lingual or palatal aspects
of the marginal gingiva. Sometimes they may even the entire
crown causing difficulty in eating. The drugs, which cause the
gingival enlargement are amlodipine, nifedipine
7. Periodontitis
Inflammation represents a cornerstone of
cardiovascular disease. Inflammation can contribute to
endothelial dysfunction, with consequent impaired
vasodilation ultimately leading to alterations in the vascular
structure: Low-grade bacteremia and endotoxemia,
accumulation compounds formed under oxidative stress, as
well as cross-reactivity or molecular mimicry between
bacterial and self-antigens, have also been regarded as
additional mechanisms potentially linking periodontal disease
to systemic diseases.
A. Gingival bleeding was one of the common clinical features
seen in hypertensive patients. In most cases of arterial
hypertension the gingival mucous was characterized by
widening of lymphatic vessels and interstitial spaces. In cases
of arterial hypertension combination with inflammatory
reaction the tendency for widening of lymphatic vessels and
interstitial spaces persisted compared with cases of normal
blood pressure. It testifies to high probability of lymphogenic
generalization of inflammation. Besides, in cases of
inflammatory gingival pathology in arterial hypertension the
absolute neutrophil number was significantly higher showing
for more acute inflammatory process and greater volume of
tissue involvement. Thus, concluding that the increased
periodontitis in hypertensive patients could probably attributed
as one of the manifestation of hypertension.
 HOSPI LAB
B. Lichen planus like lesions or lichenoid reactions are white
lesions characterized by linear striations occurring on the
buccal mucosa. They are seen bilaterally and usually in the
posterior regions. These are sometimes seen in hypertensive
patients as a manifestation secondary to the use of the drug or
medication. The most common drugs causing this side effect
are the ACE inhibitor drugs especially the captopril.
C. Hypo salivation was also found as one of the clinical
manifestations in hypertensive patients. This hypo salivation
was related to the sustained increase in both systolic as well as
diastolic blood pressure and also in patients who were under
antihypertensive medication especially with diuretics. There
will be decrease in the unstipulated saliva.
M6 - Lesson 2: Dental Management of Hypertension
DENTAL MANAGEMENT OF HYPERTENSIVE PATIENT
- A dental provider must have knowledge of the
disease, know current therapeutic options, and
possess the ability to educate and provide access to
care for patients.
- Management of the patient is mainly based on one’s
judgment as a practitioner.
- Before providing care to these patients, the
practitioner should be able to assess patient health
status
- Decisions to treat should be based on the following
factors: baseline blood pressure, urgency of the
procedure, functional and physical status, and time
and invasiveness of the procedure.
- When in doubt, consider medical advice.
LOCAL ANESTHETIC
- Local anesthetics are recommended for patients with
hypertension because they can decrease pain and
increase comfort.
- The selection of a local anesthetic : duration of the
procedure the need for hemostasis the required
degree of pain control
- Vasoconstrictors added to local anesthetics to aid in
hemostatic control and to increase the duration
- Risk of epinephrine: sympathomimetic effect on
cardiac β1-receptors.
- Avoid Norepinephrine or levonordefrin, unopposed
activation of α1-receptors in HT increase the duration
of the drug’s effect (activation lead to uncontrolled
increases in BP)
- 2% lidocaine with 1:100,000 epinephrine most
commonly used to achieve the necessary degree of
anesthesia for most dental situations.
- Maximum recommended dose of local anesthetic
solution for hypertension (poorly controlled): two
1.8- ml cartridges (total dose of 3.6 ml) with
1:100,000 (0.036 mg) epinephrine per appointment.
CONTRAINDICATIONS: LOCAL ANESTHETICS WITH
VASOCONSTRICTORS
- Include severe uncontrolled hypertension
- Caution when administering local anesthetics at
dosages higher than recommended
- Should also be aware of the potential interactions
between commonly used local anesthetics and
antihypertensive drugs
- Lengthy procedures are anticipated, the epinephrine
should be diluted to a ratio of 1:200,000.
- Apprehensive, sweating, or nervous patient likely has
increased levels of endogenous epinephrine.
- Administration of epinephrine to the nervous or
apprehensive stage 2 patient would be
contraindicated.
POTENTIAL PROBLEM RELATED TO DENTAL CARE
- Stress and anxiety may cause increase in BP; angina,
MI or CVA
- Treated with antihypertensive agents may become
nauseated or hypotensive, or may develop orthostatic
hypotension
- Excessive use of vasopressors may cause significant
elevation of blood pressure
- Sedative medication may bring about hypotensive
episode
MANAGEMENT
- Reduce stress and anxiety by premedication, short
appointments, nitrous oxide (avoid hypoxia).
- If overly stressed, terminate appointment.
- Avoid orthostatic hypotension (changing position
slowly, supporting).
- Avoid stimulating gag reflex.
- Select sedative medication and dosage cautiously.
BLEEDING
- Elevated blood pressure can lead to excessive
intraoperative bleeding.
- History of the patient and meds plays a role in
deciding when to perform certain procedures.
- Due to a number of different comorbidities, those
with hypertension may be taking blood thinners.
- It is generally recommended that for patients that
have an INR value of ≤3 for minor surgery,
anticoagulation is not terminated.
- Aspirin and other antiplatelet drugs, such as Xarelto
and Plavix the recommendation is to continue
medication for minor surgery without interruption.
- Various hemostatic agents can be used to help control
bleeding.
DRUG CONSIDERATIONS
- Minimal concentration (epinephrine 0.036 mg),
aspirate before injection and injection slowly.
 HOSPI LAB

- Caution when using vasoconstrictors in patient taking

a nonselective beta-blocker.
- Do not use gingival packing material that contains
epinephrine.
- Reduce dosage of barbiturates and other sedative
(action may enhance by antihypertensive agent).
- antihypertensive agent).
- Epinephrine used judiciously with MAO inhibitor.

Hypertensive Emergency Drugs

Drug (Drug Class)
- Fenoldopam (Peripheral Dopamine-1 Receptor
Agonist)
- Hydralazine (Vasodilator)
- Nicardipine (Calcium Channel Blocker
(Dihydropyridine))
- Nitroglycerin (Vasodilators)
- Esmolol (Beta Blocker (Beta-1 cardioselective))
- Labetalol (Combined Alpha/ Beta Blocker)
- Metoprolol (Beta Blocker (Beta-1 cardioselective))
- Phentolamine (Alpha Blocker (Nonselective))
- Clonidine (Alpha-2 Agonists, CentralActing)
- Captopril (ACE Inhibitor)

Medications Related to Dental Practice

- Alpha Blockers
- Angiotensin II Receptor Blockers
- Beta-Blockers
- Diuretics
- ACE Inhibitors
- Calcium Channel Blockers
- Beta Adrenergic Blockers
- Vasodilators