dental consideration in the management of hepatic patient

1. Dental Management of Patients with
Hepatic Disorders
By
Dr. Soad Abdel Moniem
Associate Professor in Pediatric Dentistry and Dental Public Health
Department

2. • The liver is a large organ, that occupies the upper right
quadrant of the abdomen.
• It develops as an outgrowth of the gut
• The liver retains normal function until 85% damaged.

3. Function of the Liver
1.Metabolism / Detoxification
• Metabolizes products of digestion
• Glucose regulation
• Vitamin storage
• Metabolizes drugs
• Breaks down bilirubin

4. 2. Synthesis and Secretion
• Components of clotting factors
• Cholesterol, triglyceride synthesis
• Bile production
• Other proteins and hormones
3. Storage and Filtration of Blood
• Acts as a blood reservoir
• Contains phagocytic cells
Function of the Liver (cont.)

5. Liver Function Tests (LFTs)
1. AST (aspartate aminotransferase) (11 – 47
IU/L)
• AST is an enzyme found throughout the body, but
predominantly in heart and liver cells.
• Most useful in detecting liver damage due to
hepatitis, drugs toxic to the liver, cirrhosis, and
alcoholism.
• Often ordered in conjunction with ALT.
.

6. 2. ALT (alanine aminotransferase) (7 – 56 IU/L)
• An enzyme found mostly in the cells of the liver and
kidney. When the liver is damaged, ALT is released
into the blood stream.
• ALT is a useful test for detecting liver damage.
• Most useful in detecting damage due to hepatitis
and drugs or other substances toxic to the liver.
• Often ordered in conjunction with AST.
Liver Function Tests (cont.)

7. 3. AST/ALT Ratio
• The AST/ALT ratio is usually increased in alcoholic
hepatitis, cirrhosis, and in the first day or two of acute
hepatitis or injury from bile duct obstruction
4. ALP (alkaline phosphatase) (30 – 120 IU/L)
• Found in bone and in the cells of bile ducts. ALP can
indicate blockage of one or more bile ducts, liver
cancer, hepatitis, cirrhosis, or when hepatotoxic drugs
are taken.
Liver Function Tests (cont.)

8. 5. Total Bilirubin (0.2 – 1.2 mg/dL)
• A breakdown product of hemoglobin (orange-yellow
pigmented).
• Unconjugated (non-water soluble) bilirubin is
processed in the liver.
• High unconjugated bilirubin means either
hemoglobin is being broken down too fast, or the
liver can’t process it fast enough.
• High conjugated bilirubin indicates that bilirubin is
backing up in the liver.
Liver Function Tests (cont.)

9. 6. Albumin (3.5 – 5.3 g/dL)
• A protein made by the liver. Low levels indicate
liver disease or nephrotic syndrome.
7. Prothrombin Time (PT) (10 – 14 seconds)
• The prothrombin time (PT) test measures how
long it takes for a clot to form in a sample of
blood.
• Evaluates the overall ability to produce a clot in a
reasonable amount of time.
8. Platelet Count (150,000 – 450,000 mm3)
• Thrombocytopenia is a decrease in the number of
circulating platelets.
Liver Function Tests (cont.)

10. •Low grade fever, upper abdominal discomfort and fatigue.
• Itching, nausea and vomiting.
•Thrombocytopenia.
•Bleeding tendency.
•Portal hypertension& oesophageal varices
Clinical Features

11. •Caries prevention.
•Medical consultation.

12. •Infection control measures.
•HBV vaccination
•Post exposure prophylaxis
•Routine dental treatment can be carried out without any
particular problem.
•Teeth erosion may occur due to gastric regurgitation.

13. Ab prophylaxis +Blood
transfusion
Delayed
Wound
Healing
Bleeding
Tendency
Infection

14. Type of drug Drugs
containdicated
Alternatives to
be used
Analgesics Aspirin
NSAID
Opioids
Codeine
Acetaminophen
Paracetamol
Antimicrobials Clindamycin
Doxycycline
Minocycline
Tetracycline
Ketoconazole
Penicillin
Amoxicillin
Ampicillin
Erythromycin
Nystatin
Local
anaethesia
Lidocaine Articaine
Prilocaine
General
anaethesia
Halothane
Propofol
Isoflurane
Sevoflurane
•Impaired drug metabolism.

15. •Viral hepatitis.
•Drug-induced hepatitis
•Autoimmune hepatitis.
•Liver cancer.
•Liver transplantation.

16. Hepatitis A:
It is caused by hepatitis A virus (HAV), spread
of hepatitis A is faeco-oral due to consumption of
contaminated food or water.
Clinical Features:
•The incubation period is 2-6 weeks
•Fatigue, nausea and vomiting.
•Low grade fever, jaundice and itching.
Viral Hepatitis

17. Hepatitis B (Serum Hepatitis):
•Spread of hepatitis B is mainly parenteral (via
unscreened blood or blood products, intravenous drug
abuse, and by tattooing /body piercing), sexual relations.

18. Clinical Features:
•Incubation period is 2-6 months.
• Fever, anorexia, malaise and nausea.
• Jaundice pale stools & dark urine.
•The liver is enlarged and tender.
•Complications: carrier state, chronic infection, cirrhosis, liver cancer
and death.

19. High –Risk groups for Hepatitis B:
•Patients (e.g. haemophiliacs, thalassaemiacs).
•Patients receiving haemodialysis .
•Immunosupreessed or immunodeficient patients.
• Laboratory personnel & surgeons.
•Intravenous drug abusers.
•Tattooing and acupuncture.
•Newborns whose mothers are infected with HBV.

20. Dental Aspects:
•Pure parotid saliva does not contain HBsAg, however,
saliva collected from the oral cavity may contain HBV.

21. Hepatitis C:
•Clinical manifestations are usually less severe than
hepatitis B.

22. Dental Aspects:
•HCV has been found in saliva and infection has followed
human bite.
•HCV infection may be associated with oral features like
lichen planus.

23. Halothane, some NSAIDs, some herbs, nutritional
supplements and many other drugs can cause hepatitis.

24. • It is associated with autoantibodies and often
progresses to cirrhosis.
•It responds to immunosupressants.

25. •Liver cancer in the early stages is usually asymptomatic.
•Later, manifestations may include jaundice, pain or
swelling in the abdomen, anorexia and fever.

26. • All liver transplants recipients require immunosupressive
drugs to prevent graft rejection.
Dental Aspects:
•Bleeding tendency and impaired drug metabolism.
•Children with transplanted liver may have retarded tooth
eruption, discolored and hypoplastic teeth.
•Gingival swelling due to cyclosporin intake.