Module 5C:

Dental Management of
Patients with Hepatitis
Prepared by: Dr. Maria Luisa Ramos - Clemente
• Hepatitis, or inflammation of the liver, can be caused by several
different viruses.
• Symptoms of hepatitis are universal, regardless if caused by an
infectious agent or chronic condition, and can include fatigue,
anorexia (lack or loss of appetite for food), abdominal pain, fever,
diarrhea, vomiting, jaundice, dark urine, and pale clay-colored stools.
• The mode of transmission, communicability, and incubation period
differ greatly with the type of virus.
 Lesson 1:
Importance of Liver
Liver
• Largest lobed glandular organ in the body and is located in the upper
right quadrant of the abdomen.
• It is made up of 4 lobes; a large right lobe, a smaller left lobe and small
quadrate and caudate lobes (superficial or accessory lobes).
• It is the body’s filter and warehouse.
• Almost all cells and tissues in the body depend on the liver. When
something goes wrong with the liver, it can have a serious effect on
almost every other organ in the body.
• The liver controls blood-clotting factors, which prevent excessive
bleeding.
Functions of the Liver
1. Bile formation and secretion
• Emulsifies fat and facilitates its absorption
• Bile is composed of water, bile salts and a yellow pigment
called bilirubin (breakdown product of hemoglobin)
• In patients with liver disease, bilirubin accumulates in plasma due to
decrease liver metabolism and transport.
2. Carbohydrate metabolism
• Maintains normal glucose concentration in the blood stream through:
• Release of glucose from glycogen
• Conversion of galactose and fructose into glucose
• Conversion of some amino acids to glucose (through gluconeogenesis)
3. Fat metabolism
• Fatty acids are broken down for energy if glucose is not available
• Cholesterol is formed for steroid hormone production
• Some carbohydrates and proteins are converted into fats
4. Protein metabolism
• Urea is formed
• Plasma proteins, including clotting factors are manufactured. Vitamin
K, catalyze prothrombin into thrombin in the liver

5. Removal, excretion, detoxification and inactivation of drugs,

hormones and toxins take place in the liver
 Lesson 2:
Types of Hepatitis
What is Hepatitis?
• Is a general term that means inflammation of the liver.
• The Ancient Greek word hepa refers to the liver, and itis means
inflammation.
Inflammation of the liver has several possible causes, including:
• Toxins and chemicals such as excessive amounts of alcohol
• Autoimmune diseases that cause the immune system to attack
healthy tissues in the body
• Fat which may cause fatty liver disease
• Microorganisms, including viruses
Types of Hepatitis:
1. Infectious – Viral infection of the liver due to acute or chronic viral
hepatitis (HAV, HBV, HCV, HDV, HEV).

2. Non-infectious – Due to excessive or prolonged use of toxic

substances that are metabolized in the liver (e.g. acetaminophen,
alcohol, halothane, ketoconazole, methyldopa and methotrexate) and
sometimes due to auto immune system response in the body.
 Lesson 3:
Types of Viral Hepatitis
1. Hepatitis A (RNA-Picornavirus)
• Transmission: enteric (fecal-oral route)
• Often occurs as an epidemic because the reservoir for infection is frequently a
common food or water source
• Incubation period:  25 days
• Persons of any age may be infected but occurs primarily in children and young
adults
• Mild severity
• No carrier state
• Recovery conveys immunity against infection
2. Hepatitis B (DNA-Hepadnavirus)
• Transmission:
• Direct percutaneous inoculation or transfusion of infected blood or products
• Indirect percutaneous introduction of infected blood and blood products
through minute skin cuts or abrasion
• Absorption of infected blood or blood specimen into the mucosal surface of
the mouth or eye
• Absorption of infected secretions like saliva and semen into mucosal surfaces
• Transfer of infected serum or plasma through inanimate environmental
surfaces
• Fecal transmission does not occur. Airborne droplets not important
• Incubation period: 75 days
• Permucosal and percutaneous inoculation of infectious saliva is
necessary for transmission of the disease
• Compared with Hepatitis A, Hepatitis B tends to have greater
associated morbidity or mortality, especially in the very young and
older patients
3. Hepatitis C (RNA-Flaviviridae)
• Transmission: Parenteral (primarily by blood to blood products)
• Accounts for 90-95% of all cases of post-transfusion hepatitis
infections
• Similar to HBV in behavior and characteristics
• Unprotected sex and perinatal transmission have not been recognized
as significant factors
• Incubation period: 80 days
4. Hepatitis D (defective RNA virus)
• Uses the Hepatitis B surface antigen (HBsAg) for its viral envelope
• Occurs as a co-infection in patients with acute Hepatitis B and as a
super-infection in Hepatitis B virus carriers
• Transmitted parenterally by infected blood or blood products
• Frequently associated with more severe fulminant infections than
infection with Hepatitis B alone (Hepatitis B/D > Hepatitis B)
• Incubation period: 35 days
5. Hepatitis E (non-developed RNA virus)
• Enterically transmitted Hepatitis Non-A-Non-B (NANB) virus
• Perinatal transmission possible. 20% fatality rate in pregnant women
in their third trimester
• Incubation period: 40 days
Clinical Signs and Symptoms:
• Appearances of types A, B, C, D and E hepatitis are similar
• Characterized by degeneration and necrosis of liver cells: entire liver
lobule is inflamed
• Presents in three phases:
1st phase – Prodromal phase (pre-icteric)
1. Resembles flu-like symptoms (anorexia, nausea, vomiting, fatigue,
myalgia, malaise, fever). May also demonstrate arthralgia (pain in a
joint), rash and angioedema (swelling in the deep layer of the skin).
2. Symptoms present 1-2 weeks before the onset of jaundice
2nd phase – Icteric phase
1. Clinical jaundice (yellowish brown hue of the eyes, skin, oral mucosa
and urine)
2. Some prodromal symptoms may subside but gastrointestinal
symptoms increases
3. 2-8 weeks
4. (+) hepatomegaly (enlarged liver) and splenomegaly (enlarged
spleen)
3rd phase – Convalescent/Recovery phase (post-icteric)
• Symptoms disappear but abnormal liver function and
hepatomegaly may persist
• Recovery period usually completed 4 months after onset of
jaundice. Hepatitis B and C have longer recovery periods