Dental Consideration of liver disorder patients

‫امنه خالد‬:‫اعداد‬
‫ مهند عبد الحليم كاظم‬.‫د‬: ‫باشراف‬
 Introduction

• Liver disorder are important to the dentist due to apotential bleeding

tendency,intolerance to drugs (e.g. general anesthetics,
benzodiazepines)and the possibility of underlying infective causes for the
liver dysfunction.
• Signs of liver disease include jaundice, spider naevi, leuconychia,finger
clubbing, palmar erythema, dupuytren’s contracture, sialosis and
gynaecomastia.
• Patients with parenchymal liver disease have impaired hemostasis and
can present serious bleeding problems.
• Disorders associated with an early rise in serum levels of conjugated
Bilirubin can cause dental hypoplasia and greenish ddiscoloratio of the
teeth.
• Liver Transplant : Pre-transplant Comprehensive dental evaluation
Extraction of infected, non-restorable, or periodontally hopeless teeth.
Oral hygiene instruction Post-transplant No elective dental tx for 3 months
following surgery Routine Ab prophylaxis is not recommended Recall
program after 3 months Prophylactic care
• Severe bleeding can occur after ddenta extractions in patients with
chronic liver disease and hence the clotting status must be tested.
• The commonest liver function test (LFT) involves the measurement of
aspartate transaminase (AST) and alanine transaminase (ALT). ALT may
also be raised in cardiac or skeletal muscle damage and is therefore not
specific for liver diseases .
• Difficult or impossible to identify carriers of HBV, HCV, HDV. Most
carriers are unaware that they have had hepatitis Standard precautions
HBV vaccination Post exposure prophylaxis Shaniscurto tumblr.

Oral Manifestations of Liver Disease

• Oral candidiasis – Immunotherapy

• Angular cheilitis - Immunotherapy
• Atrophic glossitis – Anemia
• Petechiae - Thrombocytopenia
• Lichen planus – HCV
• Oral metastases of HCC manifest as hemorrhagic expanding masses
located in the premolar and ramus region of the mandible.
 Dental Drugs

• caution Acetaminophen - use caution Narcotics - increase dose interval,

short term Morphine – safe .
• Anesthetics
• Lidocaine, mepivicaine - limit to 300 mg max dosage
• Prilocaine - limit to 400 mg max dosage
• Articaine - safe (metabolized in plasma)
• Sedatives / Anxiolytics
• Benzodiazepines - reduce dosage, increase intervals
• Antibiotics
• Beta - lactam (penicillins, ampicillin, cephalexin, cefazolin, ceftriaxone) -
safe (renal excretion) Metronidazole - interface w / alcohol Clindycin
aminoglycosides - use caution Tetracyclines - reduced dosage, increase
intervals.
• Coagulation PT / INR, Platelet count requirements for surgery: Maximum
INR 3.5 Minimum platelets 50,000 • 2 units fresh frozen plasma (FFP) + 6
pack platelets (60,000).

Hepatitis
1. Hepatitis:DENTAL MANAGEMENT: Medical Considerations Petlents With
a History of Hepatitis.
• Most carriers of HBV, HCV, and HDV are unaware that they have had
hepatitis,For those patients who report a positive history of hepatitis,
additional historical information sometimes may be of help to the
clinician in determining the type of disease. An additional consideration
in patients with a history of hepatitis of unknown type is the use of the
clinical laboratory to screen for the presence of HBSAG or anti-HCv.
This may be indicated even in patients who specifically indicate which
type of hepatitis they had, because information of this type derived from
the patient's history is unreliable 50% of the time.
a. Patlents at High Risk for HBV or HCV Infection.
• Several groups are at unusually high risk for HBV and HCV infection.
Screening for HBSAg and antiHCV is recommended for individuals who
fit into one or more of these categories unless they are already known to
be seropositive. In addition, the patient might have undetected chronic
active hepatitis, which could lead to bleeding complications or drug
metabolism problems.
b. Patients Who Are Hepatitis Carriers.
• If a patient is found to be a hepatitis B carrier (HBsAg positive) or to
have a history of hepatitis C, standard precautions (Appendix B) are to
be followed to prevent transmission of infection. In addition, some
hepatitis carriers may have chronic active hepatitis, leading to
compromised liver function and interference with hemostasis and drug
metabolism.
• Physician consultation and laboratory screening of liver function are
advised for determination of current status and future risks .
c. Patients with Signs or Symptoms of Hepatitis.
• Any patient who has signs or symptoms suggestive of hepatitis should
not be given elective dental treatment but instead should be referred
immediately to a physician. Necessary emergency dental care should be
provided with the use of an isolated operatory and minimal aerosol
production .
d. CDC Guldelines for Exposure to Blood.
• To reduce the risk of transmission of hepatitis viruses, the CDC has
published postexposure protocols for percutaneous or permucosal
exposure to blood. Implementation of these protocols is dependent on
the virus present in the source person and the vaccinated state of the
exposed person • Briefly, a vaccinated individual who sustains a
needlestick or puncture wound contaminated with blood from a patient
known to be HBsAg positive should be tested for an adequate titer of
anti - HBs if those levels are unknown. If levels are inadequate, the
individual immediately should receive an injection of HBIG and a vaccine
booster dose If the antibody titer is adequate, nothing further is required.
• If an unvaccinated individual sustains an inadvertent percutaneous or
permucosal exposure to hepatitis B, immediate administration of HBIG
and initiation of the vaccine are recommended
2. Hepatitis: DENTAL MANAGEMENT Medical Considerations Exposure
Control Plan.
• With respect to hepatitis viruses, the U.S. Occupational Safety and
Health Administration mandates that all employers must maintain an
exposure control plan and must protect employees from the hazards
of bloodborne pathogens by applying standard precautions and by
 providing the following as a minimum: Hepatitis B vaccinations to
employeesPostexposure evaluation and follow - up Recordkeeping of
exposures Generic bloodborne pathogen training Personal protective
equipment at no cost to employees .

Alcoholic liver disease

1. Dental Management of the Patient With Alcoholle Liver Disease
1. Detection by such methods as : History ,Clinical examination ,Alcohol
odor on breath iv. Information from family members or friends.
2. Referral or consultation with physician to ascertain the following:
Verify history, Check current status ,Check medications,Check
laboratory values Discuss suggestions for management,Alcoholic liver
disease.
3. Laboratory screening (if not available from physician) to record the
following Complete blood count (CBC) with differential ii. Aspartate
aminotransferase (AST), alanine aminotransferase (ALT) iii. Bleeding
time iv. Thrombin time v. Prothrombin time.
4. Assessment of risk of adverse outcomes associated with invasive
procedurer infection with prognostic formula.
5. Minimizing of drugs metabolized by liver.
6. If screening tests are abnormal, for surgical procedures ,
consideration is given to thrombin, gelfoam, antifibrinolytic agents,
fresh frozen plasma, vitamin K, platelets - with the help of a physician
or PharmD.
2. Alcoholic liver disease: DENTAL MANAGEMENT Treatment
Considerations.
• In addition to the considerations mentioned earlier, three major dental
treatment considerations apply for a patient with alcoholism: Bleeding
tendencies,Unpredictable metabolism of certain drugs, Risk or spread of
infection.
• A CBC with differential, AST and ALT, bleeding time, thrombin time, and
prothrombin time are sufficient in screening for potential problems.
Abnormal laboratory values, accompanied by abnormal clinical
examination or a positive history, provide the basis for referral to a
physician for positive diagnosis and treatment.A patient with untreated
alcoholic liver disease is not a candidate for elective, outpatient dental
 care and should be referred to a physician.Once the patient has been
managed medically, dental care may be provided after consultation with
the physician.
3. Alcoholic liver disease: DENTAL MANAGEMENT Treatment Planning
Modifications
• Patients with cirrhosis tend to have more plaque, calculus, and gingival
inflammation than those without the condition.
• The dentist should not provide extensive care until the patient
demonstrates an interest in, and an ability to care for, his or her
dentition. Liver enzyme induction and central nervous system effects of
alcohol in patients with alcoholism may require increased amounts of
local anesthetic or the use of additional anxiolytic procedures.

Conclusion
Management of patient with hepatitis and alcoholic liver disease became a
challenge to a dentist (s) he does not have good knowledge of such
disorder. Proper knowledge and proper application of prevention protocol
minimizes the risk of spreading the Infection also minimizes the further
complication of the condition thus reducing the mortality.

References
1. Line, J. W. (2013). Dental management of the medically compromised
potent. St Louis, Mo: El vier / Mosby
2. http://absonline.org (2001-2013 by American Association for Cinical
Chemistry)
3. http://www.merckmanuals.com/professional Index.htm (2004-2012
Merck) Sharp & Dohme Corp) 4. Robbins & Cotran (2010). Pothobgk
Bosis of Discose, 8th Edition. Saunders Elsevier 5. Patton, L. (2012).
The ADA Practical Guide to patients with