The management of the hepatopathic patient, with particular reference to the chronic subject undergoing viral infection, has for many years been one of the most relevant issues in the dental profession. These pathologies have a very high weight in social, health and socio-economic terms in the different countries: the phenomenon has in fact worldwide epidemiological relevance, with 350 million people chronically affected by the hepatitis B virus and 120-170 by HCV. In Italy, the introduction of HBV vaccination for newborns and populations at risk has led to mass immunization. This naturally excludes the approximately 600,000 Italians who report previous chronic pathology, often contracted in childhood.
The picture related to hepatitis C is worrying, as its genotypic variability continues to represent an obstacle to the development of a vaccine. There are about one million chronic patients (negative record in Europe, including in terms of mortality), one-third of whom suffer from cirrhosis. The regions most affected are concentrated in the South: Campania, Puglia, and Calabria.
These data do not take into account the emergence of non-infectious disease conditions, such as alcoholic hepatopathy and non–alcoholic steatohepatitis (NASH).
Every year 20,000 patients are lost due to the consequences of chronic liver diseases. The HCV virus is the sole cause or contributing cause of 65% of such cases.
In 2015 the Ministry of Health promoted a National Plan for the prevention of viral hepatitis (PNEV) B and C: among the key objectives, the strengthening of preventive policies related to methods at risk, with reference, among others, to clinical procedures in dentistry.
From the point of view of the clinical approach, chronic pathology can present itself with pictures varying in severity. A compensated picture does not in principle place limitations on the treatment plan, except in the use of drugs subject to potential hepatotoxicity.
A condition of cirrhosis, in which the organ is at least partially compromised from a functional point of view, associated for example with coagulopathy, is more complex. The use of drugs with hepatic metabolization should be reduced or avoided.
In the specific case of the local anesthetic, the lack of use is not conceivable with a clear indication. Dosage should therefore be kept to a minimum, ideally with 1 or 2 cartridges. As far as the type of drug is concerned, the current market does not include a drug expressly contraindicated in the hepatopathic patient (bupivacaine is not recommended in the most serious cases). It should be remembered, however, that all local dental anesthetics currently in use belong to the class of starches which, unlike esters, engage the liver in the metabolization phase. The only exception is articaine, whose molecule has an additional ester group, which induces a partial plasma metabolization. However, it should be stressed that most of the possible complications related to local anesthetics are due to overdose or incorrect administration, for example intravascular.