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Liver Disease

Risks to the dental patient

Dental Management

Questions to Ask 

Clinical Findings 

Prevention 

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

Introduction

  • Causes of Liver Disease

    • Viral hepatitis

      • Can present as acute or chronic persistant disease

      • Can result in inflammation and destruction of the liver

    • Alcoholic liver disease can result in the following:

      • Fatty liver

      • Hepatitis

        • Sudden onset after years or decades of heavy alcohol use

        • Characterized by actue or chronic inflammation and parenchymal necrosis of the liver

      • Advanced cirrhosis

        • Esophageal varices

        • Ascites

        • Hepatoma

        • Hepatic encephalopathy

    • Hepatocellular carcinoma

      • 80% are related to cirrhosis

  • Increased bleeding risk

  • Altered metabolism of medications

    • Increased risk of overdose

    • Irregular metabolism of drugs used in dentistry in patients with alcoholic liver disease

      • Early disease - increased doses required of local anesthesia and pain medication may be required due to phenomen of tolerance 

      • Late disease - decreased doses required leading to increased risk of overdose

  • What type of liver disorder do you have?

  • What is the underlying cause of your liver disease?

  • What type of treatment did you/are you having for your liver disease?

  • Is your liver disease considered to be chronic?

  • Are there medications that you have been told you cannot take?

  • How often do you see your physician?

  • What medications are you taking?

  • Do you have increased bleeding tendency?

  • Jaundice of oral mucosa and/or skin

  • Conjunctival icterus

  • Hematomas, ecchymoses, petechiae of oral mucosa, skin

  • Spontaneous bleeding of the gingiva and mucosal tissues

  • Required for patients with active hepatitis, chronic hepatitis, cirrhosis

  • What is the severity of the patient's liver disorder?

  • What medications is the patient taking at this time?

  • Is the patient being treated for any other medical conditions?

  • What is the extent of liver dysfunction?

    • What is this patient's most recent INR and bleeding time?

    • What adjustments should be made for dosing medications metabolized in the liver? (or "I would like to use/prescribe X medication.  What adjustments should be made for dosing?)

  • To control bleeding

    • Platelet transfusions (thrombocytopenia)

    • Fresh frozen plasma (factor-related coagulopathy) or intranasal desmopressin

    • Vitamin K injections

  • Limit or avoid use of drugs metabolized in the liver

    • Acetaminophen

    • Aspirin

    • Ibuprofen

    • Codeine

    • Meperidine

    • Diazepam

    • Barbiturates

    • Metronidazole

    • Vancomycin

    • 2% lidocaine (3 cartridges is considered to be a limited amount of drug)

  • Patients with early acute infection

    • Symptoms are similar to upper respiratory infections

    • Difficult to identify

    • Patients with any acute disease including colds and flu should be reappointed

  • Patient with active, diagnosed hepatitis

    • No dental treatment other than urgent care (which should be provided only in an isolated operatory)

    • Avoid drugs metabolized in the liver

    • Pre-operative INR and bleeding time should be obtained prior to surgery

  • Patient with chronic HBV/HCV carrier state

    • Request medical consultation

    • If laboratory tests indicate no significant liver dysfunction, no modifications in the treatment plan

  • Patient with cirrhosis

    • Request medical consultation regarding bleeding and medication dosing adjustments.

Viral Hepatitis

Prevention of Liver Damage

  • Acetaminophen is now the most common cause of acute hepatic failure and the second most common cause of liver failure requiring a liver transplant.

  • Doses of up to 4,000 mg/day are considered safe = 8 tablets of 500 mg acetaminophen

    • Manufacturers are required to limit the amount of acetaminophen to no more than 325 mg/unit

  • ​Taking more, especially over 7000 mg/day can lead to severe overdose

  • Many overdoses are a result of the patient taking multiple medications, including pain relievers and medications for cold and flu with acetaminophen

    • Rx of Norco 10/325  Sig: 1 tab q3-4h prn pain.  Not to exceed 60 mg hydrocodone (6 tablets) - 1950 mg - in 24 hours.

    • If the patient is unaware that Norco has acetaminophen, they might ALSO take Tylenol in addition to the Norco.  As few as 11 Extra-strength Tylenol (5500 mg) tablets increases the acetaminophen dosage to over 7000 mg

    • A patient might also be taking Mucinex Fast-Max, an OTC ​​medication for cold and flu relief.  One dose contains 650 mg acetaminophen, not to exceed 6 doses in 24 hours (3900 mg)

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