what should a dentist do when a patient with liver disease comes to dental clinic?

1. Management of patient with Liver
disease having dental problem
Dr Jameel kifayatullah

2. Major considerations
• Unpredictable hepatic metabolism of drugs
administered or prescribed in dental
treatment
• Potential for impaired hemostasis and
bleeding diathesis due to thrombocytopenia
or reduced hepatic synthesis of coagulation
factors
• Increased risk of infection, or spread of
infection, including SBP

3. main complications
The main complications of the patient with
liver disease are
• risk of contagion (for healthcare personnel
and other patients)
• the risk of bleeding
• the risk of toxicity due to alteration of the
metabolism of certain drugs.

4. concerns
• Macrocytic anemia secondary to alcoholic
liver disease causing vitamin B 12 Deficiency
• Thrombocytopenia secondary to
hypersplenism and increased sequestration
• Elevated Blood urea nitrogen and creatinine
levels especially in hepatorenal syndrome
• Hypokalemia and hypomagnesia
(malnutrition)

5. concerns
• Elevated Prothrombin time, elevated partial
thromboplastin time, and INR(decreased
synthesis of coagulation factors)
• Hypoalbuminemia
• Elevated Liver function tests(LFTS) reflecting
heptocellular dysfunction

6. Implications for patients receiving
dental treatment
• Liver disease has important implications for
patients receiving dental treatment . The most
frequent problems associated with liver
disease in clinical practice refer to the risk of
viral contagion on the part of the dental
professionals and rest of patients (cross-
infection), the risk of bleeding in patients with
serious liver disease, and alterations in the
metabolism of certain drug substances which
increases the risk of toxicity

7. MANAGEMENT
• Always after contacting the responsible physician, careful
dental examination and assessment of this dental condition
should be undertaken. It is the doctor who must inform the
dentist and make decisions about:
• The degree of liver dysfunction.
• The patient’s ability to undergo dental treatment.
• The need for chemoprophylaxis for dental treatment.
• The need to take precautions to avoid serious bleeding
• The patient’s blood test results including the number of
white blood cells (WBC), blood flow time, platelet count
and gastrointestinal control (PT, TT, aPTT), and decide
whether to use Hemostatic agents, fresh plasma, vitamin K
or platelet delivery

8. MANAGEMENT
• Attempt to learn the cause of the liver problem
• Strict sterilization measures required, since
deficient sterilization can expose both the dentist
and other patients to hepatitis infection
• The universal protective measures are applicable
in order to prevent cross-infection, i.e., the use of
barrier methods, with correct sterilization and
disinfection measures

9. MANAGEMENT
• Surgery is contraindicated in patients with certain
conditions such as acute hepatitis, acute liver
failure or alcoholic hepatitis
• If invasive measures are required, prior
coagulation and hemostasis tests are required:
complete blood count, bleeding time,
prothrombin time / international normalized
ratio (INR), thrombin time, thromboplastin time
and liver biochemistry (GOT, GPT and GGT)

10. MANGEMENT
• In the event altered test values are detected,
the hematologist or liver specialist should be
consulted with the postponement of elective
treatment
• Any emergency treatments should be
provided in the hospital setting

11. MANAGEMENT
• In the event of surgery, trauma should be
minimized in order to optimize hemostasis, with
a careful surgical technique, applying pressure to
control bleeding and using hemostatic agents
• Based on the laboratory test findings and the
treatment to be carried out, local hemostatic
agents may be advisable (oxidized and
regenerated cellulose), as well as antifibrinolytic
agents (tranexamic acid), fresh plasma, platelets
and vitamin K

12. Management
• Antibiotic prophylaxis is suggested, since liver
dysfunction is associated to diminished
immune competence
• drugs metabolized in the liver may have to be
used with caution or their doses reduced.

13. MANAGEMENT
• Certain substances such as erythromycin,
metronidazole or tetracyclines must be avoided
entirely
• Most of the antibiotics prescribed for oral and
maxillofacial infections can be used in patients with
chronic liver disease, and in general the beta-lactams
can be administered(amoxicillin,cephalopsporins)
• Aminoglycosides can increase the risk of liver toxicity in
patients with liver disease, and so should be avoided.
• The metabolism of clindamycin in turn is prolonged in
such patients, and different studies suggest that it
contributes to liver degeneration

14. MANAGEMENT
• Nonsteroidal antiinflammatory drugs (NSAIDs) should be used with
caution or avoided, due to the risk of gastrointestinal bleeding and
gastritis usually associated to liver disease. Prophylaxis can be
provided in the form of antacids or histamine receptor antagonists
Acetaminophen (paracetamol) is to be avoided in patients with
serious liver disease
• Aspirin and NSAIDs are not indicated in patients with altered
hemostasis
• Authors such as Douglas et al. (27) describe acetaminophen as a
safe alternative to aspirin or NSAIDs that can be administered at
doses of up to 4 g/day during two weeks without adverse liver
effects, warning patients to avoid alcohol consumption while
receiving treatment with the drug.

15. Management
• In patients using benzodiazepines, the dose
should be lowered, with prolongation of the
interval between doses.
• Local anesthetics are generally safe provided
the total dosage does not exceed 7 mg/kg,
combined with epinephrine
• Attempt to avoid situations in which patient
might swallow large amounts of blood