Liver disease&cardio-vascular diseae

Lecture4
Liver disease
Hepatitis:
liver consist of cell called hepatocyte and the inflammation of these cell called hepatitis.

Cause of hepatitis
1-infectious:a-Bacterial(tuberculosis-syphilis).
b-Viral (infectious mononucleus hepatitis).
2-non infectious:(toxin substance, alcohol)
Liver function
1-secretion of bile.
2-Convert the sugar to glycogen.
3-Eecretion of bilirubin:that help in the absorption of fat by the bile.
Types of hepatitis
1-HepatitisA:called infectious hepatitis .it is RNA virus , transport by contaminated water and food (oro-fecal route).Usually affect any age but mostly children, young adult. If age less than 15 years old affect by hepatitis A and full recovery.If age more than 15years old affect by hepatitis B.There no carrier stage in hepatitis A and the incubation period is 25day.represent mild to moderate in it is severity.
2-HepatitisB:It is DNA virus, the incubation period 75 days, it is very severand have carrier stage. The route of transmission by(blood transfution, drug abusers, haemodialysis, health workers, homosexual, heterosexual, haemophilia).
3-HepatitisC:It is DNA virus, incubation period 50 days.Resembletohepatitis B transmitted by (blood transfution, drug abusers, haemodialysis, health workers, homosexual, heterosexual, haemophilia).
4-HepatitisD:It is RNA virus, it is usually superinfection. It is very severe and incubation period 35days.
5-HepatitisE: It is RNA virus, transmitted by orofecal route, incubation period 40 days and transmitted by inflamed bite and not by saliva.
Manifestation
1-Alanin transferase(ALT or SGOT) and Aspertatetransferase(AST or SGPT) all these enzymes increase in liver disease.
2-Bilirubin test.
3-Alkaline phosphatase: normal or low.
4-Seriological test.
5- prothrombintime:if double value more than 28 means liver disease.
6-Bleeding time increase.7-Platelet count.
Dental management
1-Check prothrombin time, bleeding time and platelet count.
2-Wear double gloves, face mask, eye glasses.
3-Vaccine to the dentist.4-In the operative (movement of bur slowly). 5-Drugs(NSAID, Ampicillin) not give because there is metabolism disorder.

Lecture5
Cardio-Vascular disease
Examination

1-General examination of the patient(general appearance of patient) which include:
a-Color of the face(pale).

b-cyanosis which divided into:1-central such as color of lip and tong which give sign to MI, lymphoma and others

.2-peripheral which give sign to ranus phenomena.

c-Finger clubbing characterized by biconcave finger which either cardiac disease or pulmonary infection as emphysema, right side heart failure.

3-Pulse sensation:which include volume, rhythim , rapid pulse.Irregularrhythim caused by Artrial fibrillation and the complication cause Cardio-Vascular accident.

Cardio-Vascular disease:
I-Hypertention:normal blood pressure 120/80 and may be 140/90 which increase with age. There is two types:a-Essential which without etiology. b-secondarywhich associated with renal disease and others.
Dental aspect

1-Appointment in the late morning.
2-anesthesia without adrenaline.
3-monitor blood pressure.
4-vasodilator drug(nitroglycerine).
5-avoid sodium containing solutions.
6-low dose of NSAID because it decrease the effect of antihypertensive drugs.
II-Cardic disease:
1- congenital heart disease: such as tetralogy of fallot, transposition of the great vessels, ventricular septal defect, artrialseptal defect, open ductusarteriosus, coarctation of aorta, pulomary stenosis, mitral valve prolapse, aortic stenosis and bicuspid aortic valve.The preventive measures recommended in thesecases are:
?? Consultation with the physician treating the patient
?? Premedication 1 h before the surgical proceduremight be helpful
?? If recommended by the cardiologist: administrationof antibiotic prophylaxis, according to the regimenfor rheumatic heart diseases involving valvedamage
?? Use of vasoconstrictors at the smallest possible concentration
?? Short appointments, as painless as possible
2- Aquired heart disease:
a- Angina Pectoris

Angina pectoris is considered a clinical syndrome thatis characterized by temporary ischemia in part of orall of the myocardium, resulting in diminished
resulting in diminished oxygen supply. An episode of angina pectoris presents as brief paroxysmal pain posterior to the sternum, may be precipitated by fatigue, extreme stress, or a rich meal, and subsides within 2–5 min after rest and the use of vasodilators. The patient may describe the episode as painful discomfort in the chest, with a burning sensation, pressure, or tightness. Pain may be present in the cardiac area, radiating to the left shoulder, neck, left arm (with a numb sensation as well as tingling), sometimes down the chin and teeth of the mandible (usually the left side), or it may even be felt at the epigastrium, causing confusion in diagnosis. Perspiration, extreme anxiety, and a feeling of imminent death often accompany these painful symptoms. Patients with a history of coronary heart disease
have a greater chance of exhibiting angina pectoris during a dental appointment, due to the anxiety and stress of the upcoming procedure.
The preventive measures suggested in this case are:
?? Appropriate premedication, usually 5–10 mg diazepam (Valium) or 1.5–3 mg bromazepam (Lexotanil) orally, 1 h before the surgical procedure may be helpful
?? Dental surgery in hospital, when the patient refers many episodes of angina pectoris
?? Small amounts of vasoconstrictors in local anesthetic with particular importance of aspiration
?? Short appointments, as painless as possible.
b-Myocardial Infarction
Myocardial infarction refers to the ischemic necrosis of an area of the heart, usually due to complete blocking of some of the branches of the coronary arteries.A myocardial infarction has a sudden onset with severe pain posterior to the sternum, which increases
in severity rapidly and is characterized by a burning sensation, pressure, and extreme tightness. The pain is more severe compared to that of angina pectoris, lasting
longer than 15 min and does not subside with rest or use of nitrates sublingually. Pain usually radiates (as in angina pectoris) to the left shoulder or towards
the ulnar surface of the arm. It may also radiate towards the neck region, the mandible, teeth, midback region, epigastrium, and the right arm. The pain may
also be associated with nausea, vomiting, perspiration, and dyspnea.
It is not always possible to treat patients in the dental office if they have suffered a myocardial infarction. It is considered prudent to avoid any routine dental surgery on patients with recent infarctions (within the last 6 months). In cases where treatment is deemed absolutely necessary (acute infection, pain, etc.), management
should take place in a hospital. Six months following the myocardial infarction, patients may also be treated in the dental office, as long as the dentist follows the same recommendations as those that were described in the case of angina pectoris.
c-Rheumatic Heart Disease
Patients with a history of rheumatic fever may have damage of the mitral and aortic valves, which may be described as stenosis, or insufficiency, or both. Because patients with such a disease may develop clinical manifestations in the cardiovascular system years later, they must be evaluated very carefully before the surgical procedure is performed in order to determine if they can actually handle the stress involved.
It is also extremely important for the dentist to realize that transient bacteremia, which in healthy patients is nonthreatening and which may develop after invasive surgical procedures, is considered especially dangerous for patients belonging to this category. In this case, the endocardium generally presents great sensitivity to bacterial infection, and, as a result, any invasive procedure in the oral cavity without the use of antibiotics results in greater risk of bacterial endocarditis. The preventive measures that are recommended are:Premedication before the surgical procedure can be helpful
?? Avoidance of vasoconstrictors (or maximum concentration 1:100,000)
?? Small amounts of vasoconstrictors in local anesthetic with particular importance of aspiration .
Lecture6
Diabetes Mellitus
Diabetes mellitus is a syndrome characterized by alteration of the metabolism of carbohydrates, proteins, and lipids and is caused by abnormalities of the secretion
mechanism and effect of insulin. The dentist must be extremely careful about performing
surgery on a diabetic patient, as far as the following are concerned.Screening Tests.A recent blood glucose test is important. This test may be performed in the dental office before surgery using a glucometer, a portable piece of equipment that is battery operated. A drop of capillary blood from the fingertip is placed on the test strip after pricking with a special lancing device, and within 1 min a numerical value appear on the screen.fast normal value 120 while non fast 200 .
Scheduled Time of Surgery.In order to avoid the risk of a hypoglycemic reaction (insulin shock), it is best if surgery is performed in the morning, 1–1.5 h after breakfast (insulin’s peak action is noted in the afternoon). This way, the patient comes to the dental office rested and without stress..
Postoperative Recommendations.Patients with controlled diabetes do not require preoperative or postoperative antibiotic prophylaxis. These people should be treated in the same way as nondiabetic dental patients.
Administration of Local Anesthetics.Local anesthetics must be administered with great care, because of the vasoconstrictor, whose concentration must be minimal. Adrenaline, which is one of the most commonly used vasoconstrictors, causes glycogenolysis, thus interacting with insulin. Noradrenaline has less of a glycogenolytic effect compared to adrenaline, and so is preferred in diabetics. Generally, though, the amount of vasoconstrictor in an ampoule is very small (the greatest concentration being 1:50,000) and so the risk is considered minor.
Administration of Other Drugs.Mild analgesics and sedatives containing acetaminophen (Tylenol) are used. Corticosteroids must be avoided because of their glycogenolytic action, as should salicylates (aspirin), due to potentiation of the hypoglycemic action of the antidiabetic tablets. The administration of an anxiolytic
is recommended the previous afternoon and the morning before the surgical procedure.
Wound Healing. Surgical procedures in the oral cavity must be performed with gentle manipulations for optimal wound healing. Bone edges must be smoothed
in order to avoid irritation of the gingiva. Suturing may be helpful.
Blood Glucose Level at the Time of Surgery.Generally, there is no specific blood glucose level that is prohibitive for emergency dental procedures. If surgery is not imperative, then it is better if it is postponed and the patient’s blood glucose level is controlled.
Dental Office Supplies.For treatment of an emergency situation such as hyperglycemia or hypoglycemia, insulin, sugar or glucose solution, saline solution, glucose, etc. should be available at the dental office.Diabetic hypoglycemia is most important, presenting when the blood glucose level is below 55 mg/100 ml.


Written by:
Mushtag t. mohammed