DENTAL CONSIDERATIONS IN LIVER DISORDER

PATIENTS

PRESENTED BY:NAMBINAYAKI.E.MPG TRAINEEORAL AND MAXILLOFACIAL SURGERY

LIVER•Liver is situated in the abdominal cavity below the right hypochondrium extending upto epigastrium

• It is divided into the right and left lobes by the falciparum ligament, more specifically by the hepatic blood supply.

LIVER•The liver consists of reticulo-endothelial cells and the hepatocytes(80%) •The reticulo-endothelial cells constitute the mononuclear phagocytes,kupffer cells ,sinusoids,stellate cells and cholangiocytes.

•Hepatocytes are arranged in three zones ZONE 1: Closer to the portal vein and hepatic artery therefore highly oxygenated and nutrient rich blood.

ZONE 3: Farther away from the portal traid and close to the hepatic so comparatively less oxygenated.

ZONE 2: Midway between zone 1 and zone 3

CAUSES

PATHOPHSIOLOGY•Hepatocyte damage•Necrosis of the liver cells•Fibrosis •Regeneration

LIVER DISORDERS -DIAGNOSISLIVER FUNCTION TESTS 1.Bilirubin 2.Albumin 3.AST ,ALT 4.Alkaline phosphatase 5.Gamma-glutamyl transferase

HAEMATOLOGICAL TESTS 1.Anaemia- normochromic normocytic- due to GI tract bleeding. hypochromic microcytic- due to iron deficiency

2.Leucopenia – portal hypertension due to hyperspleenism Leucocytosis- due to liver cells disorders.

3.Thrombocytopenia- decreased production of platelets due to deficiency of thrombopoietin hormone which is produced in liver.

4. Coagulation disorders – prolonged prothrombin time is valuable diagnostic information.,since the half life of vitamin K dependent clotting factors are short(5-72 hours)

IMMUNOLOGICAL TESTS: “Chronic liver disease screen” 1.hepatits B surface antigen 2.hepatitis C antibody 3.liver autoantibodies

RADIOLOGIC IMAGING

ALCOHOLIC LIVER DISEASE• Alcoholic liver disease is hepatic injury due to consumption

of alcohol. The risk factors for alcoholic liver disease are 1.Drinking pattern 2.Gender 3.Genetics 4.Nutrition

PATHOPHYSIOLOGY

DRUG-INDUCED LIVER DISEASE• HEPATOXIC DRUGSLOCAL ANESTHETICS 1.Lidocaine 2.Prilocaine 3.Mapivacaine 4.BupivacaineANALGESICS 1.Aspirin 2.Acetaminophen 3.Ibuprofen

SEDATIVES 1.Diazepam 2.BarbituratesANTIBIOTICS 1.Tetracycline 2.Erythromycin 3.Amoxiclav 4.ClindamycinANTIFUNGALS 1.Ketaconazole 2.Fluconazole

• According to guidelines drugs metabolized in the liver must reduced in dosage when one or more of the following is present.

1.Aminotransferase levels elevated to greater than 4 times normal values(8-40U/L) 2.Serum bilirubin elevated above 2mg/dl 3.Serum albumin levels lower than 35mg/dl 4.Signs of ascites and encephalopathy and prolonged bleeding time

• A quantity of three catridges of 2% lidocaine is considered safe.

HEPATITIS• Hepatitis is the inflammation of the liver• It may be due to infections or non-infectious HEPATITIS

INFECTIOUS NON-INFECTIOUS

1.VIRAL HEPATITS2.INFECTIOUS MONONUCLEOSIS3.SECONDARY SYPHILIS4.TUBERCULOSIS

1.ALCOHOLIC LIVER DISEASE2.DRUG INDUCED LIVER DISEASE

VIRAL HEPATITIS – AN OVERVIEW

• Certain group of viruses are associated with liver diseases• HEPATITIS A- Infectious hepatitis

HEPATITIS B

HEPATITIS –C - Flavivirus

HEPATITIS-D : Delta virusHEPATITIS E- non-A non-B virus hepatitis F, hepatitis G and transfusion transmitted viruses (TTV) and candidate viruses associated with hepatitis E .

PATHOPHYSIOLOGY

HEPATOCYTE DAMAGE

DECREASED ADH DECREASED ANDROGEN AND ESTROGEN DETOXIFICATION

DECREASED METABOLISM OF CARBOHYDRATE,PROTEINS,FATS

LIVER INFLAMMATION

ALTERATIONS IN BLOOD AND LYMPH FLOW

LIVER NECROSIS

INCREASED WBC

DECREASED VITAMIN K ABSORPTION DECREASED BILE MEATBOLISM

PALMAR ERYTHEMA LOSS OF BODY HAIRGYNACOMASTIA

EDEMA ACITES ,EDEMA BLEEDING TENDENCIES

JAUNDICE

CHRONIC HEPATITIS: Chronic infection is characterized by presence of virus in liver and serum antigens for more than 6 months.

FULMINANT HEPATITIS: Rapidly progressing sudden damage of the liver cells which charecterized by a mortality rate of 80%.

CLINICAL SIGNS AND SYMPTOMSPRE-ICTERIC(1-2 weeks after incubation period) 1.fever,fatigue,malaise,malaise 2.anorexia 3.nausea,vomitting 4.abdominal pain

ICETERIC 1. Jaundice 2.hepatomegaly 3.spleenomegaly

RECOVERY PHASE: Symptoms disappear but abnormal liver functions, hepatomegaly and splenomegaly persist.

MANAGEMENTIMMUNIZATION

ACTIVE IMMUNIZATION: Immunity acquired after exposure to antigen,antibodies are created by recipient and are stored permanently.eg.VaccinesVaccine is an antigenic substance prepared form causative agent of disease used to provide immunity against several diseases.

ACTIVE

PASSSIVE

PASSIVE IMMUNITY: This occurs naturally(from mother to foetus) or artificially when antibodies are transferred to non-immune individuals.

STRATERGY FOR HBV TRANSMISSION

A stratergy for interrupting HBV transmission in all age groups was developed in 1991 and updated in 1995 which includes

1. prevention of peri-natal HBV infection 2. routine vaccination of infants 3.vaccination of high risk induviduals.

MANAGEMENT FOLLOWING ACCIDENTAL EXPOSURE

TREATMENT

PALLIATIVE

DIET MODIFICATIONREST

MEDICAL

INTERFERON alfa 2bPeglated interferon

Lamivudine-HBVRIBAVIRRIN-HCV

DENTAL MANAGEMENT• All patients with a history of viral hepatitis must be managed as

though they are potentially infectious.

• According to the CDC and American Dental Association cross infection can be prevented by

1.following universal precautionary measures. 2.vaccination against hepatitis B infection. 3.Health care must be provided only in an isolated operatory. 4.Aerosols should be minimized and drugs metabolized in the liver must be avoided as much as possible.

5. If surgery is recommended a complete liver screen must be done and prothrombin time must be analysed. 6. Immediately after exposure HBIG and vaccines must be given 7. All health care workers must be provided with vaccines at an interval of 6months with a booster dose if nessasary. 8. Strict sterilization protocols must be followed 9. If accidental exposure occurs ,abundant irrigation with water,saline is advised ,the rationale behind this being to reduce the number of viral counts to below threshold count nessasary to produce infection.

DIAGNOSIS 1.History- viral hepatitis,drugs,alcohol 2.Clinical examination

REFERRAL OR CONSULTAION WITH PHYSICIAN 1.Verify history 2.Check the medications 3.Check current status 4.Check laboratory values 5.Discuss sugestions for management.

LABORATORY SCREENING 1.Complete blood count 2.AST and ALT values 3.Bleeding time 4.Pro-thrombin timeAssesement of risk adverse outcomes associated with invasive

procedures using Child-Pugh classification.Minimizing of drugs metabolized by liverIf screening tests are abnormal, for surgical procedures.,

THROMBINANTI-FIBRINOLYTIC AGENTSGELFOAMFREAH FROZEN PLASMAVITAMIN-K INJECTIONS

• CHILD-PUGH CLASSIFICATION This score is used to assess the prognosis of chronic liver disease and to predict mortality during surgery

MINOR SURGICAL PRCEDURES IN LIVER DISORDER PATIENTS•Minor surgical procedures such as

extraction,impaction,incision and drainage can be performed in patients after a proper liver screen is obtained.• Platelet counts are assessed.• If the LFT levels are 3 times higher than normal values ,prior

to minor surgical procedure a dose of fresh frozen plasma is given,vitamin k injections may be given in obstructive jaundice.

Haemostatic agents like gelfoam,antifibrinolytic agent,thrombin can be used.

MAJOR SURGICAL PRCEDURES• Major surgical procedures can be delayed in a patient with active

hepatitis unless it is extremely urgent.

• LFTS are assessed and the extent and cause of liver damage is diagnosed, treatments are modified according to the cause.

• A physician opinion is advised.

• Clotting factors, fresh frozen plasma, vitamin k injections and haemostatic agents are used.

CONCLUSION Management of a patient with liver disorders is of challenge to the

dentist.

Proper prevention control measures must be followed

Strict sterilization must be done to prevent cross-infection.

Drugs must be properly chosen and administered.

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