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LIVER DISEASE Date of Publication: June 20, 2019 Disease/Medical Condition LIVER DISEASE Date of Publication: June 20, 2019 (also known as “hepatic disease”) Note: Viral hepatitis is further addressed in fact sheets entitled “Hepatitis A”, “Hepatitis B”, and “Hepatitis C.” Liver transplantation is further addressed in the fact sheet entitled “Organ Transplantation.” Alcohol and drug dependencies are further addressed in the fact sheet entitled “Substance Use Disorder”. Is the initiation of non-invasive dental hygiene procedures* contra-indicated? Yes, if the patient/client has active viral hepatitis (acute, chronic, or relapsing) or is otherwise potentially infectious. Possibly, if the patient/client has undergone liver transplantation (e.g., during the immediate post-transplantation phase, in which only emergency oral care is indicated). Is medical consult advised? — Yes, if the patient/client has history or systemic manifestations suggestive of active viral hepatitis (acute, chronic, or relapsing) or previously undiagnosed chronic carrier state. — Yes, if patient/client is not receiving ongoing medical care/monitoring for recently acquired hepatitis A or E. — Yes, if patient/client is not receiving ongoing medical care for chronic carrier state of viral hepatitis (for hepatitis B or C). — Yes, if patient/client has significant morbidity, including prolonged bleeding time or other manifestations of severe or end-stage liver disease. — Yes, if the patient/client has pending, or has already undergone, liver transplantation. Is the initiation of invasive dental hygiene procedures contra-indicated?** Yes, if the patient/client has active viral hepatitis (acute, chronic, or relapsing) or is otherwise potentially infectious. Yes, if there is prolonged bleeding time (e.g., resulting from viral hepatitis or related to severe or end-stage liver disease from any cause). Yes, if the patient/client has undergone liver transplantation, because immunosuppressive medication may affect appropriateness or safety. Yes, if the patient/client is significantly immunosuppressed from any cause (e.g., from corticosteroids or other immunosuppressive drugs used in the treatment of autoimmune liver disease). Yes, if drug or alcohol dependency is of a type or extent that may affect appropriateness or safety of invasive procedures. Is medical consult advised? See above. Is medical clearance required? — Yes, if active viral hepatitis (acute, chronic, or relapsing) and/or prolonged bleeding time and/or severe liver disease is suspected on the basis of history and/or examination. — Possibly, in the case of hepatitis B or C, if the patient/client is being treated with antiviral medications associated with immunosuppression +/- increased risk of infection +/- prolonged hemostasis. Patients/clients on antiviral therapy should be assessed by their physician prior to invasive dental procedures to ensure safety. — Yes, if the patient/client has untreated alcoholic liver disease. Elective, outpatient dental/dental hygiene care should be deferred pending assessment by a physician regarding bleeding risk, etc. — Possibly, in severe or end-stage liver disease, if the patient/client’s medical status (e.g., hepatic encephalopathy) could pose a safety risk to the patient/client or the dental hygienist. — Yes, for the patient/client who has undergone liver transplantation. Bloodwork should be conducted prior to dental hygiene treatment to determine if the patient/client’s platelet count, clotting factors, and absolute neutrophil count are sufficient to prevent hemorrhage and infection. cont’d on next page... Disease/Medical Condition LIVER DISEASE (also known as “hepatic disease”) Is the initiation of invasive dental hygiene procedures contra-indicated?** (cont’d) Is antibiotic prophylaxis required? — Possibly, if the patient/client has undergone liver transplantation (especially during the immediate post-transplant period). Medical/dental input should be sought for evaluation of medically-induced immunosuppression and infection risks.1 — No, for most patients/clients with liver disease. However, patients/clients with severe liver disease may be more susceptible to dental infection (as a result of disease- or medication-related immunosuppression), and antibiotic prophylaxis may be a consideration. Is postponing treatment advised? — Yes, if the patient/client has active viral hepatitis (acute, chronic, or relapsing) or is otherwise potentially infectious; is not receiving ongoing medical care/monitoring for chronic viral hepatitis carrier state or severe liver disease (of any cause, including alcoholic liver disease); or is suspected to have prolonged bleeding time2. See “medical consult” above. — Possibly, if the patient/client has undergone liver transplantation (depends on timing of invasive procedures relative to transplant procedure and degree of patient/client’s immunosuppression). Refer also to “Organ Transplantation” fact sheet. — Yes, if the patient/client is medically unstable. Oral management implications Patients/clients with liver disease can pose a significant challenge for the dental hygienist, because the liver plays a vital role in various metabolic and biochemical functions.3 In particular, bleeding tendencies and impaired drug metabolism may need to be addressed in the dental/dental hygiene treatment plan. Liver dysfunction is common in patients/clients who abuse alcohol or parenteral drugs. Dental surgery is contraindicated in patients/clients with acute hepatitis, acute liver failure, or alcoholic hepatitis. Acetaminophen (which can cause hepatotoxicity) should be avoided in patients/clients with severe liver disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution, if at all, due to the risk of gastrointestinal bleeding and gastritis associated with severe liver disease. Aspirin and NSAIDs are contraindicated in patients/clients with altered hemostasis. Based on laboratory test findings that demonstrate bleeding tendency, local hemostatic agents and antifibrinolytic agents (e.g., tranexamic acid) may be indicated for invasive dental/dental hygiene procedures. In patients/clients with advanced liver disease, drugs metabolized mainly in the liver (such as local anaesthetics including lidocaine) may need to have their dose reduced. Certain antimicrobials (such as erythromycin, metronidazole, and tetracycline) should be avoided entirely. However, most antibiotics prescribed for oral and maxillofacial infections (including beta-lactams, such as penicillin derivatives and cephalosporins) can be safely used in patients/clients with chronic liver disease. Some general anaesthetics (e.g., halothane and thiopentone) are generally contraindicated in patients/clients with severe liver disease. Nitrous oxide and isoflurane are usually preferred. The efficacy and safety of many drugs are influenced by concomitant alcohol consumption. Pre- and post-transplantation considerations are described in the “Organ Transplantation” fact sheet. 1 Patients/clients who have undergone liver transplantation may already be on prophylactic antibiotics and/or antifungals (e.g., nystatin) and/ or antivirals (e.g., acyclovir). Additional or alternative antibiotic prophylaxis may be required for invasive dental hygiene procedures. 2 If the patient/client is at risk for excessive bleeding, coagulation and hemostasis tests should be sought prior to dental/dental hygiene treatment. In the event of abnormal test values, consultation with a hepatologist or hematologist should occur, with postponement of elective treatment. Emergency treatments should be provided in a hospital setting. 3 Metabolic functions include conversion of sugar to glycogen, secretion of bile for fat absorption, and excretion of bilirubin. Biochemical functions include synthesis of coagulation factors and breakdown of drugs. cont’d on next page... 2 Disease/Medical Condition LIVER DISEASE (also known as “hepatic disease”) Oral manifestations Ecchymoses, petechiae, hematomas, gingival bleeding, jaundiced (yellowish) mucosal tissues, glossitis (especially in alcoholic liver disease), lichen planus, and impaired healing may be signs of liver disease. Candidiasis, angular cheilitis, and chronic periodontal disease are common findings in patients/clients with advanced liver disease. Crusted perioral rash and bruxism may also be manifestations. Endogenous staining of the teeth can result from neonatal liver disease.4 In biliary atresia, a green discolouration of the primary dentition may occur. In neonatal hepatitis5, the primary teeth may take on a yellowish-brown colour. Gingival fibromatosis is a component of several rare genetic syndromes that have liver manifestations (e.g., Laband syndrome in which there is hepatosplenomegaly). Gingival tissue enlargement usually begins early in life, and within a few years the teeth are nearly or completely covered with firm tissue with a granular, corrugated surface. The enlarged gingivae are typically pale in appearance, and the gingival enlargement leads to protrusion of the lips. Tremors of the tongue can occur during alcohol withdrawal. Poor oral hygiene and neglect (as manifested by caries) are common manifestations of chronic alcoholism. Other stigmata include angular cheilitis, glossitis, and loss of tongue papillae, which result from nutritional deficiencies. In addition, spontaneous gingival bleeding and mucosal ecchymoses and petechiae can result from vitamin K deficiency, impaired hemostasis, portal hypertension and splenomegaly (causing thrombocytopenia). Sialadenosis6
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