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Pharmacology · patient case with 2 questions

Viral hepatitis and a history of opioid misuse

Patient: Male, 41 years old

Chief complaint: “I need this tooth out, it's been aching for a week.”

History: HIV on antiretroviral therapy. Chronic hepatitis B and hepatitis C co-infection with documented hepatic impairment. History of opioid use disorder, currently in recovery for 18 months.

Findings: Non-restorable tooth #31 with a chronic apical abscess. Moderate pain. INR mildly prolonged at 1.4.

Question 1

Which analgesic should NOT be prescribed to this patient?

  1. Ibuprofen at standard dose
  2. A local anaesthetic long-acting block for immediate relief
  3. Hydrocodone
  4. Acetaminophen at a reduced daily maximum
Show answer and explanation

Correct answer: C. Hydrocodone

  • A. Ibuprofen requires caution in advanced liver disease because of gastrointestinal bleeding risk and effects on renal perfusion, but it is not the prohibited drug here and short-course NSAID use is often the appropriate choice.
  • B. A long-acting local anaesthetic block, bupivacaine for instance, is an excellent opioid-sparing strategy for exactly this patient.
  • C. CORRECT. HYDROCODONE is an opioid, and this patient has a documented history of OPIOID USE DISORDER in sustained recovery. Prescribing an opioid risks precipitating relapse and undermining 18 months of recovery. Non-opioid analgesia plus definitive treatment of the source is the standard of care, and where an opioid is genuinely unavoidable it should be prescribed in consultation with the patient's addiction physician, in the smallest quantity, with the patient's knowledge and consent.
  • D. Acetaminophen is hepatically metabolised and its ceiling dose must be reduced in liver disease — commonly to 2 g per day or less — but at a reduced dose it remains usable and is often preferred over NSAIDs.

Note: The definitive treatment is extraction. Analgesic choice is a bridge, and the best opioid-sparing plan is prompt removal of the source of pain.

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Question 2

What infection control precautions are required for this patient?

  1. Airborne precautions with an N95 respirator
  2. Standard precautions
  3. Treatment only in a hospital operating theatre
  4. Treatment deferred until viral loads are undetectable
Show answer and explanation

Correct answer: B. Standard precautions

  • A. Airborne precautions are for AIRBORNE pathogens — active pulmonary tuberculosis, measles, varicella. Blood-borne viruses are not transmitted by the airborne route.
  • B. CORRECT. STANDARD PRECAUTIONS are applied to EVERY patient regardless of known infection status, precisely because a patient's status is often unknown. They fully cover blood-borne viruses — HIV, hepatitis B and hepatitis C — through gloves, mask, eye protection, gown, safe sharps handling, and appropriate instrument reprocessing. No additional precautions are required for blood-borne pathogens.
  • C. Hospital treatment is not indicated by blood-borne viral status. It might be considered for severe hepatic coagulopathy, but an INR of 1.4 does not require it.
  • D. Deferring care until viral loads fall is discriminatory and clinically unjustified, and it would be an ethical and legal violation. The patient has an active infection needing treatment.

Note: Hepatitis B is the most transmissible of the three by percutaneous exposure, which is why HBV vaccination for dental personnel is mandatory. Post-exposure risk after a needlestick runs roughly: HBV 6–30 percent unvaccinated, HCV about 1.8 percent, HIV about 0.3 percent.

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