Dental considerations in patients with liver disease
What is the liver?The liver is the largest solid organ in the body, and is also considered a gland because it makes and secretes bile.
It is located in the upper right portion of the abdomen protected by the rib cage. It has two main lobes that are made up of tiny lobules.
The liver cells have two different sources of blood supply. The hepatic artery supplies oxygen rich blood that is pumped from the heart, while the portal vein supplies nutrients from the intestine and the spleen.
The liver functions include:
Production of bile that is required in the digestion of food, in particular fatsStoring of the extra glucose or sugar as glycogen, and then converting it back into glucose when the body needs it for energy
Production of blood clotting factors
The processing and storage of iron necessary for red blood cell production
The manufacture of cholesterol and other chemicals required for fat transport
The conversion of waste products of body metabolism into urea that is excreted in the urine
Metabolizing medications into their active ingredient in the body
Liver diseases are very common and can be classified into:
Acute (characterized by rapid resolution and complete restitution of organ structure and function once the underlying cause has been eliminated)
Chronic (characterized by persistent damage, with progressively impaired organ function secondary to the increase in liver cell damage). Based on the extent and origin of the damage, chronic liver disease ranges from fatty liver to hepatocellular carcinoma, and includes hepatitis, fibrosis and cirrhosis.
Liver diseases can also be classified into
Infectious (hepatitis A, B, C, D and E viruses, infectious mononucleosis and tuberculosis)
Non-infectious (Fatty disease, Liver cirrhosis, Liver cancer)
Classic symptoms of liver disease include:
Nausea,vomiting,
Right upper quadrant abdominal pain
Jaundice (a yellow discoloration of the skin due to elevated bilirubin concentrations in the bloodstream).
Fatigue, weakness and weight loss may also be occur.
Infectious diseases
Hepatitis A:Hepatitis A is a viral liver disease that can cause mild to severe illness.
The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
Almost everyone recovers fully from hepatitis A with a lifelong immunity.
Hepatitis A treatment usually focuses on keeping comfortable and controlling signs and symptoms
However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis. The patient is able to transmit the infection during the incubation period (2-6weeks).
Hepatitis B:
Hepatitis B is a worldwide health problem, with an estimated 400 million carriers of the virus, Hepatitis B virus is highly infectious in blood and other body fluid.
An important consideration among dental professionals is the risk of percutaneous
transmission through punctures or cuts with instruments infected from HBV-positive patients, or absorption through the mucosal surfaces (eyes).
The diagnosis of acute HBV infection is made by recognition of the clinical features, specific serologic tests for viral antigens and antibodies, and elevated liver enzymes. The hepatitis B surface antigen (HBsAg) is the first detectable specific marker.
Interferon is the drug of choice for patients with chronic viral hepatitis.
Vaccination is the most effective means of preventing HBV infection. The incubation period lasts 2-6 months. Over 50% of all infections are subclinical and are not associated with jaundice.
Hepatitis C:
Hepatitis C virus (HCV) infection is the main cause of chronic liver disease and of liver-cirrhosis. It has been estimated that 8000 to 10,000 deaths a year are attributable to HCV and the latter represents the main indication for liver transplantation in Europe and the United States.The sources of contagion include percutaneous exposure through contaminated instruments, and occupational exposure to blood. The incubation period is long (up to three months), and 85% of all patients with HCV infection develop chronic hepatitis. No effective vaccine against HCV has yet been developed .The existing therapy comprises combination treatment with interferon and ribavirin, which offers a sustained response rate of 30-40%.
Chronic Hepatitis
Chronic hepatitis is a diffuse inflammatory disorder of the liver with a duration of over 6 months in which the underlying cause can be infectious (mainly hepatitis C virus and, to a lesser extent hepatitis B).
Fatty liver
Defined as the accumulation of fat (mainly triglycerides) in the liver, this disorder is mainly associated toobesity, diabetes, hyperlipidemia and insulin resistance
drugs, poisons, and too much alcohol
No clear treatments have been established to date for fatty liver only by treated underlying cause
Liver cirrhosis
Is irreversible, and is characterized by the formation of fibrous scarring in the liver, with the formation of regeneration nodules that increase resistance to blood flow through the organ. The resulting deficient liver perfusion damages vital structures in the organ and adversely affects its physiological functions. The main causes of liver cirrhosis are hepatitis B and C infection and alcohol abuse. Other potential causes are non-alcoholic fatty, genetic alterations and autoimmune disorders. The treatment options comprise suppression of the causal stimulus, antiviral therapy and liver transplantation in the end stages of cirrhotic disease.
Liver cancer
Is one of the most common and life-threatening malignancies in the world – with a survival rate after two years of only about 2% . It has been estimated that HBV and HCV are responsible for over 80% of all hepatocarcinomas. The other causes are fatty liver. Most patients with hepatocellular carcinoma have a history of cirrhosis, which in itself constitutes a preneoplastic condition.The most frequent problems associated with liver disease in clinical practice
The risk of bleeding in patients with serious liver disease, In situations of advanced liver disease, the vitamin K levels can be significantly lowered, thus giving rise to a reduction in the production of blood coagulation factors. In addition, portal hypertension can scavenge platelets formed in the spleen, thus giving rise to thrombocytopenia. This in turn can lead to an excessive bleeding tendency.Alterations in the metabolism of certain drug substances which increases the risk of toxicity.
Risk of percutaneous transmission through punctures or cuts with instruments infected from HBV- HCV positive patients, or absorption through the mucosal surfaces (eyes).
Dental management
1- Consultation with physician in order to establish which drugs are used, their doses and possible interactions and the potential coagulopathy.2-The universal protective measures are applicable in order to prevent cross-infection. Strict sterilization measures are therefore required, since deficient sterilization can expose both the dentist and other patients to hepatitis infection.
in the case of accidental perforation of the skin with instruments or needles comprise careful washing of the wound (without rubbing, as this may inoculate the virus into deeper tissues) for several minutes with soap and water, or using a disinfectant of established efficacy against the virus (iodine solutions), If exposure through some mucosal membrane has occurred, irrigation with tap water is advised, for several minutes, and receive vaccine.
3-local measure for bleeding control.