A Practical Approach to Special Care in Dentistry. Группа авторов

the intestine, malabsorption, nausea, vomiting, pain and abdominal distension can occurCoagulation factor synthesis deficiency and exacerbated fibrinolysis increase the tendency to bleedApproximately 1% of persons living with HBV infection are also infected with HIV and hence have additional signs and symptoms related to this coinfectionHDV infections occur only in those who are infected with HBV, resulting in a more serious disease and poorer prognosisHepatic cirrhosis and liver cancer can develop as a consequence of chronic HBV and HCV infection

      Diagnosis

       HBVThe laboratory diagnosis of hepatitis B is based on detecting hepatitis B surface antigen (HBsAg) in a peripheral blood sampleIn the acute phase of the infection, immunoglobulin M (IgM) against the hepatitis core antigen (HBcAg) is also detectedThe presence of hepatitis antigen ‘e’ (HBeAg) is indicative of high levels of viral replication and therefore high infection potentialChronic hepatitis by HBV is characterised by the persistence of HBsAg for more than 6 months

       HCVIn patients who have been infected by HCV, anti‐HCV antibodies are detected in serological testsTo confirm the chronic infection in patients who are anti‐HCV positive, a nucleic acid test for detecting HCV‐RNA is requiredWhen the HCV infection becomes chronic, biopsy and other less invasive tests are employed to quantify the hepatic damage

      Management

       HBVOnly 10–40% of patients with chronic hepatitis B require drug treatment, with tenofovir and entecavir the most widely used antiviral agentsIn most patients, the treatment suppresses viral replication but does not cure the hepatitisHBV can be prevented by vaccines that are safe, widely available and effective; these also provide protection from HDV infection.

       HCVMore than 95% of patients with chronic hepatitis from HCV are cured with the administration of pangenotypic direct‐acting antivirals (DAAs)These are drug combinations that mainly include sofosbuvir, velpatasvir, voxilaprevir, glecaprevir and pibrentasvirThis has reduced deaths due to liver cirrhosis and hepatocellular carcinomaThere is currently no effective vaccine

      Prognosis

       HBVCauses 650 000 deaths annually as a result of the hepatic damage caused by viral hepatitisHBV infection becomes chronic in only 5% of infected adultsHowever, 20–30% of these develop cirrhosis or liver cancer

       HCVCauses an estimated 400 000 deaths annuallyHCV infection becomes chronic in 70% of casesThe risk of cirrhosis and/or hepatocellular carcinoma within 20 years is estimated at 15–30%

      A World/Transcultural View

       Chronic viral hepatitis is especially frequent in low‐income countries, where transmission is typically mother to foetus or child to child (e.g. hepatitis B virus in Southeast Asia and sub‐Saharan Africa) or through contaminated blood (e.g. hepatitis C virus in Egypt, Pakistan and North Africa)

       A significant number of countries, particularly African, still do not universally administer hepatitis B virus vaccine to infants

       The success of a viral hepatitis detection programme depends on identifying target groups, whose beliefs and health perspectives can affect their acceptance

       Although new treatment strategies for hepatitis C have demonstrated high rates of healing, they have created new inequalities in accessing treatment in low‐ to medium‐income countries

Recommended Reading

      1 Averbukh, L.D. and Wu, G.Y. (2019). Highlights for dental care as a hepatitis C risk factor: a review of literature. J. Clin. Transl. Hepatol. 7: 346–351.

      2 Castro Ferreiro, M., Diz Dios, P., and Scully, C. (2005). Transmission of hepatitis C virus by saliva? Oral Dis. 11: 230–235.

      3 Carrozzo, M. (2014). Hepatitis C virus: a silent killer relevant to dentistry. Oral Dis. 20: 425–429.

      4 Golla, K., Epstein, J.B., and Cabay, R.J. (2004). Liver disease: current perspectives on medical and dental management. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 98: 516–521.

      5 Jefferies, M., Rauff, B., Rashid, H. et al. (2018). Update on global epidemiology of viral hepatitis and preventive strategies. World J. Clin. Cases 6: 589–599.

      6 Klevens, R.M. and Moorman, A.C. (2013). Hepatitis C virus: an overview for dental health care providers. J. Am. Dent. Assoc. 144: 1340–1347.

      7 Mahboobi, N., Porter, S.R., Karayiannis, P., and Alavian, S.M. (2013). Dental treatment as a risk factor for hepatitis B and C viral infection. A review of the recent literature. J. Gastrointestin. Liver Dis. 22: 79–86.

5 Endocrine Diseases 5.1 Diabetes Mellitus

      Section I: Clinical Scenario and Dental Considerations

      Clinical Scenario

      An 11‐year‐old girl is referred by her paediatric endocrinologist for urgent management of dental pain. The pain commenced several days ago but has substantially worsened in the last 24 hours. It is localised to #54 which was treated by her family dentist 1 year ago.

      Medical History

       Type 1 diabetes mellitus, diagnosed at the age of 5 years old

       Two episodes of severe hypoglycaemia in the last 12 months that required hospitalisation

       Currently reviewed by her paediatric endocrinologist every 8 weeks

       Coeliac disease diagnosed 6 months ago

       Generalised anxiety (worsening)

      Medications

       Fast‐acting insulin

       Long‐acting insulin (insulin glargine)

       Strict diet control, including gluten‐free foods only for the last 6 months (supervised by her mother)

      Dental History

       Regular dental attender (biannual dental check‐ups since the age of 6 years)

       Limited cooperation – sedation required when a filling was undertaken a year ago

       Patient brushes her teeth with an electric toothbrush 3 times daily, usually supervised by her mother

       Sporadically uses dental floss

       Rinses with a fluoride mouthwash each night

      Social History

       Lives with her mother (divorced) during the weekdays and her father on the weekends

       Her father is not as disciplined as her mother in relation to healthcare (e.g. diet control or tooth brushing)

       Poor relationship between her parents contributing to increasing generalised anxiety for the patient

      Oral Examination

       Good oral hygiene

       Buccal fistula adjacent to the carious #54 (disto‐occlusal filling in situ) – draining pus

       Hypomineralisation of tooth #73

       Two mouth ulcers on the right buccal mucosa (1 mm diameter)