This document provides an overview of considerations for oral surgery in patients with liver disease. It discusses the functional role of the liver and risks associated with dental care for patients with liver disease such as impaired hemostasis, drug interactions, and increased susceptibility to infection. It also covers preoperative evaluation including liver function tests and coagulation assessment. Guidelines are provided for preoperative management including vitamin K replacement, drug dosing adjustments based on liver function, and anesthesia considerations. Postoperative management focuses on hemostasis and infection control.

1. SUDIPTA BERA
FINAL YEAR BDS
HIDSAR
Hepatic Considerations in Oral Surgery

2. CONTENTS
• Functional role of liver
• Signs, Symptoms & Risks
• Liver Function Tests (LFTs)
• Bleeding and coagulation
• Drug Actions & Doses
• Child-Turcotte-Pugh classification
• Preoperative risk assessment
• Anaesthesia
• Infection exposure
• Emergencies & urgent care
• Refernces

4. Signs, Symptoms & Risks

5. Risks of Dental Care
• Impaired Hemostasis
Vitamin‐K‐dependent clotting factors II, VII, IX, & X are synthesized in liver, production is affected
in patients with liver disease leading to impaired hemostasis
• Drug Actions / Interactions
Drugs metabolised in liver show impaired metabolism leading to systemic toxicity and adverse
effects
• Patients ability to tolerate dental care
Amide group of local anaesthetics are metabolised in liver so their uses in higher doses causes
systemic toxicity. Various General Anesthetics are hepatotoxic in diseased patients.
• Susceptibility to infection
Viral hepatitis patients with active interferon treatment and liver transplant patient with
immunosuppressive therapy are at increased risk of infection
• Transmission of infection
Patients with viral hepatitis presents risk of transmission of infection to the dentist during treatment

7. Bleeding and coagulation assessment
Why is it needed?
A. Hepatocytes synthesis most blood coagulation
factors, such as fibrinogen, prothrombin, factor V, VII,
IX, X, XI, XII, as well as protein C and S, and
antithrombin. In patients with advanced liver diseases
complex alterations in the hemostatic system arise
due to impaired production resulting in imbalance of
these factors.
B. In the patient with liver disease, clinical bleeding will
be more severe, necessitating a more cautious
approach to dental surgery.
C. So, patients must be carefully evaluated for their
capacity for hemostasis, and testing should include at
minimum a platelet count, PT/INR, and PTT tests.

8. Tests
Condition Platelet count Bleeding time PT/INR aPTT
Severe liver disease

9. Surgical Procedures
• Patients with mild liver disease may have no altered platelet count or altered PT/INR
and aPTT
• In general, the platelet count should be above 50,000 and INR below 2.0–2.5 for
surgical procedures, depending on the extent of surgery
• For INR/PT < 3.5 with normal platelet count; uncomplicated forceps extractions can
be done safely with local hemostatic measure
• Invasive oral and maxillofacial procedures (ex. trauma surgery, TMJ surgery) in ASA
catagory III or higher or Child-Turcotte-Pugh class B/C requires perioperative
monitoring and management and local hemostatic agents for coagulopathy
• Elective surgery should be delayed for improvement of condition in CTP class B/C
• To minimize risk of bleeding, patients are treated over more than one visit by treating
an arch or quadrant on eash visit

10. Preoperative Management
• Consultation and referral should be provided.
• Preparation before the dental procedure may include vitamin K
replacement and platelet replacement
• vitamin K replacement, fresh-frozen plasma (FFP), and likely
cryoprecipitate transfusions to get the prothrombin time down to within
3 s of normal and to achieve a goal of platelet counts >50 000/mm3
• Vitamin K1 10 mg parenterally (phytomenadione) should be given
daily for several days pre-operatively to improve haemostatic function.
Oral vitamin K will be ineffective in the presence of chronic
malabsorption.
• Injecting 10 mg vitamin K daily, IV for 3 days. Vitamin K IV
promotes reversal in 6–12 hr
• If there is an inadequate response as shown by the prothrombin time, a
transfusion of fresh blood or plasma may be required.
• Cryoprecipitate in case on plasma fibrinogen < 1 g/lit

11. Perioperative & Postoperative Management
• Surgery in hospital setting with necessary equipments for
perioperative monitoring and life support
• Individualized dietary support and fluid therapy plans can
be used
• Electrocautery may be used if hemostasis cannot be
achieved in inflamed, highly vascular tissue or a blood
vessel in encountered
• Topical hemostatic agents ay be used to control bleeding
such as Gelfoam, HemCon Dental Dressing, or topical
thrombin.
• Hemostatic matrix such as oxycellulose, absorbable
gelatin, or collagen such as Instat, Colla-Cote
• Rinsing with an antifibrinolytic agent like tranexamic acid
or ε-aminocaproic acid (5%) 4 times a day for 2 minutes
for 2 to 5 days postoperatively

12. Drug Actions & Doses
✦ Liver plays central role in pharmacokinetics & bio transformation of drugs
✦ Liver blood flow, binding to plasma protein & biliary excretion influences
pharmacokinetics depends on normal functioning of liver
✦ Impaired drug detoxification and excretion mean that the effects of drugs are
not entirely predictable
✦ Hepatic dysfunction Increased sensitivity to both desired and adverse
effect Doses adjustments
✦ Doses adjustment can be done by reducing initial dose, increasing time interval
between doses
✦ Hepatotoxic drugs and CNS-active drugs should not be given

13. The presence of more than one of the following
findings is suggestive that drug metabolism will be
impaired:
1. Aminotransferase levels elevated to higher than
four times normal
2. Serum bilirubin level elevated above 35 mM/L
(2 mg/dL)
3. Serum albumin level less than 35 g/L
4. Signs of ascites, encephalopathy, or
malnutrition

15. Medications
Prescription: Normal &
altered
Drug alerts/advice
2% Lidocaine
(Xylocaine) with
1:80,000 epinephrine
Use only 2 carpules per visit for hepatitis or
cirrhosis
Amide LAs toxicity can occur
Minimize total amount of local anaesthetic by treating patient over multiple visit
Acetaminophen 325-650mg q8h Avoid chronic use.Maximum daily dose <2g/day with cirrhosis or chronic active hepatitis.
Absolutely avoid with alcoholic liver disease.
Oxycodone +
Acetaminophen
Hepatitis : One 2.5/325 tablet q6h
Cirrhosis : One 2.5/325 tablet q8h
Limited, low-dose therapy for 2-3 days is usually well tolerated in hepatitis or cirrhosis
Fentanyl Do not use more than 2 lozenges (200μg) at a
given time
Recommended for use in liver failure
Penicillin VK Normal Dose: 250/500mg q6h/qid x 5 days Safe to use and no dose alteration needed with Hepatitis or Cirrhosis
Amoxicillin Normal Dose: 250/500mg q8h or 500-875mg
PO q12h x 5 days
Can be used with 50% dose adjustment in a patient with both kidney and liver disease.
Cefadroxil Normal Dose: 1-2g/day in two divided doses x
5 days (250mg or 500mg/capsules)
Decrease the dose by 50% in patients with both kidney and liver disease
Clarithromycin Normal Dose: 250mg or 500mg bid x 5 days Dose adjustment is needed with moderate-severe liver disease as long as the renal
function is normal.
Clindamycin Normal Dose:150-450mg q6-8h PO x 5 days.
Prescribe the lower dose of 150mg tid or q8h
No dose adjustment required with hepatitis. Decrease the dose by 50% in patients with
cirrhosis.
Metronidazole Normal Dose: 250mg q6h or 500mg q8h x 5
days
Can be used in the presence of both liver and kidney disease but with a reduced dose,
250mg q12h
Drug Doses Modification

16. • Assessment of liver function through the Child-Turcotte-Pugh classification system may provide
guidance for modifications of drug dosages
• Class A (mild risk) is 5 or 6 points, class B (moderate risk) is 7 to 9 points, and class C (severe risk) is
≥ 10 point
• Mild liver dysfunction minimal dose adjustment is necessary,
• Substantial liver dysfunction dosages might be reduced by 50%, and some drugs must be avoided
altogether.
Child-Turcotte-Pugh classification

17. Preoperative Risk Assessment

18. Anaesthesia
• Anesthetic agents are chosen based on factors like
protein binding, distribution, and drug metabolism.
• Overall intraoperative objectives are to preserve
hepatic blood flow and oxygen supply while
minimizing exposure to hepatotoxic drugs to
prevent more liver damage
• In mild to moderate alcoholic liver disease,
significant enzyme induction is likely to have
occurred, leading to an increased tolerance of local
anesthetics, sedative and hypnotic drugs, and
general anesthesia.
• Inhalation anaesthesia (INHA) is preferred over
total intravenous anaesthesia (TIVA)

19. Local anaesthesia
1. The liver metabolizes the amide family of local anesthetics,
which includes many commonly used anesthetics, such as
lidocaine, bupivacaine, and mepivacaine
2. In patients with substantial liver dysfunction, the half-life of
local anesthetics is prolonged
3. A one-procedure dose of three cartridges of 2% lidocaine (120
mg) is considered to represent a relatively limited amount of
drug
4. Articaine is extensively metabolised in plasma while
prilocaine is partially metabolized in lungs. Since they are less
dependent on liver metabolism, they are preferred anaesthetics
in patients with liver dysfunction

20. General Anaesthesia
1. Induction - Propofol is favored due to its rapid
redistribution; quicker onset of sedation. Although doses
should be reduced due to reduction in plasma protein
(albumin).
2. Maintanance - Hepatic metabolism for desflurane (0.2%)
isoflurane (0.2%) & sevoflurane (5%) are very little,
making them the best anesthetic options for patients with
liver disease, along with nitrous oxide. Halothane, 20% of
which is metabolized by the liver, should be avoided.
3. Relaxant - Atracurium and cis-atracurium are unaffected by
liver disease
4. Opioid - Remifentanil rapidly undergoes hydrolysis, and
clearance and elimination are unaltered even in advanced
liver disease.

21. Infection Exposure
Patients with acute viral hepatitis should not receive elective dental treatment but instead
should be referred immediately to a physician
Exposure control plan
Occupational Safety and Health Administration
guideline
1. Hepatitis B vaccinations to employees,
2. Postexposure evaluation and follow-up,
3. Recordkeeping for exposure data,
4. Generic blood- borne pathogens training,
5. Personal protective equipment made available
at no cost.

22. CDC guidelines for exposures involving HBV
Post exposure protocols
CDC - The risk of contracting HBV infection from a sharps injury in health care workers
from HBV carriers may approach 30%.

23. Emergencies & urgent care
For patients with severe liver disease who require urgent
care, consider treating in a special care clinic or hospital.
When emergency dental treatment is necessary in patients
with active hepatitis, isolation is necessary.
Consultation with a physician
Limited care provided only for pain control, treatment of
acute infection, or control of bleeding until condition
improves.

24. References
• Perioperative management of patients with liver disease for non-hepatic surgery: A systematic review Atsedu Endale Simegn a,
Debas Yaregal Melesse b, *, Yosef Belay Bizuneh b, Wudie Mekonnen Alemu b
• DOSAGE ADJUSTMENT IN HEPATIC PATIENTS: A LITERATURE-BASED REVIEW : Rajib Hossain, Rummatul Annesha
Jannat, Shadia Akter Chadni, Chandon Das, SM Hafiz Hassan, Mohammad Torequl Islam
• Protocol for the management of oral surgery patients on warfarin utilizing a Point-of-Care In-Office international normalized ratio
monitoring device : Gregory P. Hatzis
• Little and Falace’s Dental management of medically compromised patients : James W. White, Craig S. Miller, Nelson L. Rhodus
• Centers for Disease Control and Prevention. Hepatitis B information for health professionals (website): http://
www.cdc.gov/hepatitis/HBV/index.htm. 2015.
• Friedman LS. Surgery in the patient with liver disease. Trans Am Clin Climatol Assoc. 2010;121:192-204.
• Golla K, Epstein JB, Cabay RJ. Liver disease: current perspectives on medical and dental management. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2004;98:516-521.
• Wedemeyer H, Pawlotsky JM. Viral hepatitis. In: Goldman L, Schafer AI, eds. Cecil Textbook of Medicine. 25th ed. Elsevier;
2016:966-973, [Chapter 150]. ISBN 978-1-4377-1604-7.
• Lindroth J. Management of acute dental pain in the recovering alcoholic. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2003;95:492-497.
• Medical problems in Dentistry: Crispian Scully
• Textbook of Oral and Maxillofacial Surgery : Neelima Anil Malik
• Dentist’s Guide to Meidcal Conditions and Complications: Kanchan Ganda
• Anaesthesia Consideration for Oral and Maxillofacial Surgeon : Matthew Mizukawa, Samuel J. McKenna, Luis G. Vega