Risk of bleeding during oral surgery in patients with liver cirrhosis: A systematic review

[Stomatological management of patients with liver disease: a review of the literature]

Introduction

The liver is the organ responsible for the metabolism of nutrients, some drugs, and the production of coagulation factors. According to the World Health Organization, approximately 23 million people worldwide are diagnosed with liver disease each year. As a result, it is common for dentists to encounter these patients on a daily basis in their practice. The objective of this review is to establish the dental management of patients with liver disease.

Material and methods

A manual literature search was conducted using the indexed articles in PUBMED and EBSCO databases using the keywords "oral surgery," AND "liver disease," AND "hepatic cirrhosis," AND "dental management".

Results

Patients with liver disease present important characteristics for the dentist, which must be recognized in order to perform procedures with the lowest risk of intraoperative and postoperative complications. A patient with poorly controlled underlying liver disease is more prone to infections and bleeding, which implies a high risk of morbidity.

Conclusions

Dental care for patients with liver disease should be assessed according to the reason for consultation, control of the disease, the complexity of the procedure to be performed, and both intraoperative and postoperative hemostatic measures. All necessary hemostatic measures should be considered and dose adjustments should be considered in the use of NSAIDs.

Nitrogenous compounds in the saliva and blood of cirrhotic patients: a cross-sectional study

OBJECTIVES

Serum increase of nitrogenous compounds (NC) in cirrhotic patients has been associated with the development of hepatic encephalopathy (HE). However, the relation between NC in saliva and HE is unclear. The objective of this study is to measure the levels of nitric oxide and urea in the blood and saliva in 38 cirrhotic patients and correlate them with clinical characteristics and presence and grades of HE.

MATERIAL AND METHODS

Automated enzymatic colourimetric assays were performed to determine the levels of NC. Diagnosis and severity of HE were determined based on the West Haven criteria and by using the inhibitory control test.

RESULTS

HE was diagnosed in 89.47% of the patients, with the majority (60.50%) presenting covert HE. With regard to the measurement of NC, although nitric oxide is moderately correlated with its amount in blood and saliva (r = 0.630; P < 0.001), only salivary levels were associated with the presence of ascites and ecchymosis (P = 0.013 and P = 0.030, respectively). In patients with HE, the serum levels of urea were higher (P = 0.013) than those in patients without HE or minimal HE.

CONCLUSIONS

Nitrogenous compounds in the saliva were correlated with neither the presence nor grades of HE, whereas in the blood, only urea was positively correlated with the severity and presence of HE.

CLINICAL RELEVANCE

Saliva is an excellent fluid for diagnosing several diseases, but it does not seem to be able to collaborate with the identification of HE.

Oral Health and Liver Disease: Bidirectional Associations—A Narrative Review

Several links between chronic liver disease and oral health have been described and are discussed in this narrative review. Oral manifestations such as lichen planus, ulcers, xerostomia, erosion and tongue abnormalities seem to be particularly prevalent among patients with chronic liver disease. These may be causal, coincidental, secondary to therapeutic interventions, or attributable to other factors commonly observed in liver disease patients. In addition, findings from both experimental and epidemiological studies suggest that periodontitis can induce liver injury and contribute to the progression of chronic liver disease through periodontitis-induced systemic inflammation, endotoxemia, and gut dysbiosis with increased intestinal translocation. This has brought forward the hypothesis of an oral-gut-liver axis. Preliminary clinical intervention studies indicate that local periodontal treatments may lead to beneficial liver effects, but more human studies are needed to clarify if treatment of periodontitis truly can halt or reverse progression of liver disease and improve liver-related outcomes.

Assessment of laboratory tests and intraoperative bleeding in patients with liver cirrhosis undergoing tooth extractions

OBJECTIVES

The objective of this study was to quantify intraoperative bleeding in patients with cirrhosis and correlate it with clinical characteristics and laboratory coagulation tests.

STUDY DESIGN

A case-control study was carried out with 74 patients with cirrhosis who were submitted to preoperative coagulation tests (complete blood count, platelet count, prothrombin time/international normalized ratio, thrombin time, activated partial thrombin time, platelet aggregation, fibrinogen, protein C, protein S, antithrombin, and von Willebrand factor level and activity). The levels of nitrogen compounds that can affect the platelet function were determined in saliva and blood by using automated enzymatic-colorimetric assays.

RESULTS

Patients with cirrhosis had changes in almost all coagulation tests. The average volumes of intraoperative bleeding and blood lost per minute in the study group (5.36 mL/min and 0.19 mL/min, respectively) were greater than those in the control group (3.05 mL/min and 0.11 mL/min, respectively; P < .05). In the control group, ascites (P = .012) and presence of periapical lesion (0.034) were positively correlated with bleeding (mL/min). With regard to coagulation tests and nitrogen compounds, only a positively moderate correlation with the platelet aggregation test was observed.

CONCLUSIONS

No patients had hemorrhagic events and it was not possible to correlate a greater amount of bleeding with coagulation tests or nitrogen compounds in the study group.