[Music] this video is sponsored by bootcamp.com check it out for iron bde prep and use coupon code mental dental for 10 off hey everyone ryan here and welcome back to our oral medicine series this video will be all about hepatitis so just like gingivitis is inflammation of the gingiva periodontitis is inflammation of the periodontium and pulpitis is inflammation of the dental pulp hepatitis is inflammation of the liver which is primarily composed of hepatocytes hence the name hepatitis now hepatitis is most commonly caused by infection with a hepatitis virus another way of saying that is viral hepatitis is the most common form of hepatitis out there and we'll dive much more into that later alcoholic hepatitis is caused by heavy and chronic alcohol use and toxic hepatitis can be caused by certain poisons chemicals medicines or supplements and these agents would be called hepatotoxins which are toxic to the hepatocytes of the liver examples of these chemicals include things like phosphorus carbon tetrachloride acetaminophen enlarged in chronic doses and chloroform and then there's also something called autoimmune hepatitis where the body's immune system attacks its own liver and the exact cause of that is not known although it probably has to do with genetics and some environmental factors so chronic viral hepatitis is also the major cause of liver cirrhosis or scarring of the liver and liver carcinoma or cancer so all these things that we talked about the hepatitis virus alcohol and certain chemicals can turn a healthy liver into one that looks like this before we dive more into hepatitis let's do a quick review of some high yield immunology so b lymphocytes or b cells mediate the humoral immunity which means it has to do with secreted antibodies and complement proteins the t lymphocytes or t cells mediate cellular immunity so the cells themselves get involved with the immune response including helper t cells and cytotoxic t cells and then all these things are antibodies salivary iga or immunoglobulin a is the main antibody found in saliva immunoglobulin e binds to receptors on mast cells and it's involved in the allergic response igg is the most common antibody in the body as a whole and then igm which we'll see a little bit later in the video is the first responder to most foreign bodies and neonatal b cells or b lymphocytes predominantly will produce this igm so as i said before let's focus on the viral form of the disease this is what's mostly tested on on the board exam so how is this disease spread well it depends on what form we're talking about so hepatitis a and e are transmitted via a fecal oral route so it's kind of gross but it means oral contact with some microorganism that comes from feces of an infected person so this typically involves ingestion of contaminated food or water hepatitis b and c are transmitted via percutaneous contact that means piercing through the skin or at a break in the skin or mucosa with contaminated blood or other bodily fluids and then lastly we have hepatitis d which is also caught with direct contact with bodily fluids of an infected person but it's usually acquired either as a co-infection or super infection in people that already have or have had hepatitis b so three memory tricks that i have to help you remember the routes of transmission for hepatitis are the phrase contaminated blood which starts with c and b the word direct which starts with the letter d and then fecal oral the two vowels in fecal are e and a so we're going to focus mostly on these first three moving forward as they're the most prevalent infectious causes of liver disease in the united states today so hepatitis a once again is transmitted by the fecal oral route e and a are those vowels of the word fecal it has a two to six week incubation period which means it may take about this long after you are infected with the virus for symptoms to begin to show up it usually has an acute rapid onset remember a for acute it does not lead to chronic disease or a carrier state so this virus won't be the one leading to cirrhosis or any long-term liver damage which is the good news for hepatitis a but some of the short-term acute symptoms we might expect are jaundice yellowing of the skin or whites of the eyes fever malaise loss of appetite and nausea those are some of the main symptoms and a vaccine for hepatitis a is currently available hepatitis b is transmitted by blood or body fluid through a break in the skin so it's very relevant for dentists this is a really good board exam question as well hepatitis b is considered a major risk for infection in a dental office because of its relatively high risk of transmission at about 30 percent and that's after percutaneous injury so a poke through the skin with an infected needle or a sharp bur could be the cause of this transmission it has a one to six month incubation period so there's a longer period of time before we start to see symptoms it's unique amidst the hepatitis viruses so all of them are rna viruses except for this one which is a dna virus and it's contained that dna material is contained within this spherical capsid called a dane particle that actually is the thing that's infecting the host cells fun fact intraorally the greatest concentration of this virus is at the gingival sulcus about one-third of cases show no signs or symptoms but symptomatic infections will show all of the same symptoms that i talked about before jaundice fever malaise loss of appetite and nausea this next point is super important for the board exam the vaccine is available and it's very effective it's most commonly administered in two or three injections over the course of six months and osha states that the hep b vaccine must be offered to all employees with occupational exposure in other words employees who could come in contact with contaminated blood and both the ada and cdc strongly recommend that all employees get this vaccine but it's not technically mandated for them the most important thing again for the board exam would be to know that this vaccine must be made freely available to all employees who come in contact with patients post-exposure prophylaxis consists of treatments with the vaccine and possibly immunoglobulin therapy and this would be administered as soon as possible after a potential exposure has happened so let's talk about some immunology stuff real quick and we're going to go over interpretation of hepatitis b serologic test results so this would involve testing someone who might potentially be infectious who may or may not have immunity who maybe had a history of hepatitis b how would we find out that information through a blood test well there are three main ones and based on if someone's positive or negative for these you can tell their current status and history with hepatitis b so the surface antigen is diagnostic a positive lab test result means that you are infectious pretty simple you have an active infection and you can spread it to other people a surface antibody indicates recovery and immunity from a hep b infection for someone who has been vaccinated against the virus so this one's also pretty straightforward if you had the vaccine you will have the surface antibody the core antibody appears at the onset of symptoms in acute or chronic hepatitis b cases and it persists for life so it'll never go away once you have it and this means that you have some natural immunity inferred from having the virus and lastly this igm antibody to the core antigen appears during acute or recent hepatitis b infections and is present for only about six months so it indicates a recent or present hepatitis b infection because that one's not going to last for the rest of your life that antibody will eventually disappear so to apply all this together let's say someone is negative for all of these tests that means they never had hepatitis b they never got the vaccine so they're susceptible to infection they have no immunity no protection whatsoever now let's say someone is negative for the first test they're positive for the second test and they're negative for the third test so this would mean they're not currently infected they can't transmit it to other people they have immunity because they got the vaccine and they never had the disease in the past so that's how you can just kind of simply go through this list and determine someone's history and potential immunity with hepatitis b and now let's go to hepatitis c once again coming from contaminated blood again c and b are those two first letters of that phrase contaminated blood but this one doesn't come up as much on the board exam because it only has a 1.8 risk of transmission after percutaneous injury despite it being much harder to transmit hepatitis c is the most common blood-borne pathogen in the us so that's still good information to know it has a two week to six month incubation period so like hepatitis b it's a slower disease process you can think of c for chronic it's usually asymptomatic but if symptoms are present they are mild and similar to all the others jaundice fatigue nausea fever muscle aches all those sorts of things there is no vaccine currently available for this one but they are working on one although there is no vaccine for hepatitis c current treatment regimens would be done with weekly interferon alpha and daily ribovirin which is an antiviral which can cure more than 90 percent of cases so it's very effective although it is very expensive while acute hepatitis like hepatitis a and some hepatitis cs can go away on their own chronic hepatitis which is usually b or c can cause liver cirrhosis and these are the cases where medication can and should be considered for patients with active hepatitis no dental treatment other than absolutely necessary work should be rendered so these patients that present for elective or non-urgent care should instead be referred to a doctor for medical diagnosis and treatment urgent care on the other hand should be provided in an isolated operatory with strict adherence to standard precautions so wear gloves masks eyewear gowns disinfect all surfaces after you're done and so on we talked about this in the hiv aids video as well aerosols should be minimized and drugs that are metabolized in the liver should be avoided if at all possible or their doses lowered as appropriate so dental drugs primarily metabolized in the liver include amide local anesthetics like lidocaine analgesics like aspirin acetaminophen and ibuprofen sedatives like diazepam and barbiturates and antibiotics like ampicillin and metronidazole in addition the cdc recommends that if dental healthcare personnel are acutely infected with hepatitis which is usually hepatitis a the acute one they should stay home from work for a week after onset of jaundice before returning to work now what about the carriers of the hepatitis virus and people who've recovered from it well there are no treatment modifications necessary just follow standard precautions like you would for any patient now the reason for standard precautions is because look most carriers of hepatitis b hepatitis c and even hepatitis d viruses are unaware that they have it since many cases are mild and not noticeable clinically which we call subclinical so we need to protect from potential infection with every patient that we see to be safe and that's why we always wear gloves and masks because we never can truly know what someone has or has already had unless they've had the whole swath of tests and of course the only way to possibly know this information at all is to take a comprehensive medical history and that's what this series has been all about we want to make sure we get all the full background of medical information that we possibly can about each patient so that we treat them in the best most appropriate way and lastly let's go over some examples of oral manifestations of liver dysfunction which i think are very important to know for the board exam so first we have jaundice and so not only can this manifest as yellowing of the skin or whites of the eyes but it can also involve yellowing of the oral mucosa we can also expect to see some patekie which are little pinpoint bleeds usually on the roof of the mouth but we might also see other signs of a tendency to bleed now why is that well the liver is responsible for making clotting factors so when the liver shuts down so does the coagulation cascade and this results in those patekie and bruises and spontaneous gingival bleeding to name a few now you might be asking what do we do for these patients well they might need vitamin k therapy or clotting factor replacement or sometimes they even need platelet replacement because they're also low on platelets feed or hepaticus is a distinctive bad breath associated with liver disease and specifically hepatic encephalopathy atrophic glossitis is a smooth tongue with no papilla on its dorsal surface xerostomia dry mouth we've seen this in most of the videos so far in this series there's also an increased incidence of hepatitis b and c in cases of lichen planus so that's interesting and chronic viral hepatitis also increases the risk of hepatocellular carcinoma which rarely metastasizes to the jaw but it has been reported to manifest as a hemorrhagic expanding mass located in the premolar or remus region of the mandible that's it for this video thank you so much for watching please like this video if you enjoyed it and subscribe to this channel for much more on dentistry if you'd like to support me please check out my patreon page and thank you to all of my patrons for their support you can unlock access to my video slides to take notes on and practice questions for the board exams so go check that out the link is in the description thanks again for watching everyone i'll see you in the next video