Pre-liver transplant protocols in dentistry

Hemorrhagic complications in individuals with liver disease submitted to minor oral surgery

Individuals with chronic liver disease (CLD) have an increased risk of bleeding from thrombocytopenia and changes in hemostasis. The aim of this study was to evaluate the frequency of and the factors associated with the occurrence of bleeding in CLD patients who underwent dental surgical procedures. This was a retrospective study whose data were collected in a hospital dentistry service between 2010 and 2016. The patients were referred from the gastroenterology and liver transplantation services of a university hospital for dental treatment. The study followed the STROBE guidelines. Among the 71 surgical procedures performed, there were 17 (24%) perioperative and postoperative bleeding episodes, 14 of which were in pretransplant patients and 11 received blood transfusion before dental surgery. Individuals with a previous history of bleeding (PR = 2.67, CI = 1.07-6.67, P = 0.035) and those with a platelet count before surgery 50 × 109/l or less (PR = 7.48, CI = 1.70-32.86, P = 0.008) had a higher prevalence of perioperative and postoperative bleeding episodes than their peers without a previous history of bleeding, and those with platelet count greater than 50 × 109/l. The approach to individuals with CLD is complex and represents a challenge to the clinician. A careful anamnesis combined with laboratory screening of coagulation disorders appears to be useful to identify individuals at a major risk of bleeding. Studies identifying the predisposing factors of bleeding in CLD patients support well tolerated protocols for oral surgery in this group.

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

BACKGROUND

The liver is responsible for the production of almost all coagulation factors, but does this indicate a risk of developing unusual bleeding in patients with liver cirrhosis during dental surgery?

TYPES OF STUDIES REVIEWED

In this systemic review, the authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and performed a search of PubMed, Latin American and Caribbean Health Sciences Literature, Web of Science, Scopus, and Cochrane databases.

RESULTS

Seven studies met the inclusion criteria. The sample sizes ranged from 23 through 318 participants, number of extracted teeth ranged from 62 through 1,183, platelet count ranged from 16,000 through 216,000 per cubic milimeter, and the international normalized ratio was less than 4. The prevalence of hemorrhagic events in the studies ranged from 0% through 8.9%, and almost all were controlled with local hemostatic measures.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

During dental treatment, patients with liver cirrhosis have a low bleeding risk in spite of the decreased number of platelets and increased international normalized ratio.

Dentistry and oral and maxillofacial surgery in the patient with liver disease: key messages for clinical practice

The recent changes in terms of both epidemiology of chronic liver disease (CLD) and long-term survival of patients with CLD have had a great impact in the field of dentistry and oral and maxillofacial surgery. In this context, compared with the previous decades, today it is more probable to cure patients with CLD also at advanced stage (cirrhosis), that could remain asymptomatic for long, before the appearance of signs of decompensation. Hence, it is crucial to identify the patient with CLD and to define the stage of the latter. The main risks are the viral acquisition on the part of the operator or of the other patients, the risk of bleeding due to the impaired coagulation status or the risk of liver decompensation due to alterations in the metabolism of certain drugs leading to hepatotoxicity. Generally, it is appropriate to treat patients with CLD not yet evolved in cirrhosis or with compensated cirrhosis, in a primary care setting, whilst secondary care management should be reserved to those patients with decompensated cirrhosis (Child-Turcotte-Pugh's grade B or C) or compensated cirrhosis but with signs of thrombocytopenia or previous episodes of decompensation. In the latter case it is mandatory to quantify the perioperative risk. In this updated review the authors describe the practical approach to the patient with CLD.

Is It Safe to Remove Teeth in Liver Transplant Patients Without Antibiotics? A Retrospective Study of 346 Patients

PURPOSE

Eradication of oral infectious foci is essential for liver transplant candidates. The main issue is whether antibiotic prophylaxis is necessary for all dental extractions despite the possible fostering of resistant bacteria. To overcome the scarcity of evidence-based data, our study analyzed the background and outcomes of a large number of routine extractions performed in our institution without antibiotic prophylaxis in patients with different liver pathologies.

MATERIALS AND METHODS

In this retrospective cohort study, the outcome of interest was the occurrence of local infections and minor complications during the 7-day follow-up period after extraction; the predictors were the demographic and clinical variables of the patients (age, gender, liver pathology, Model for End-Stage Liver Disease score, international normalized ratio) and the extraction variables (single vs multiple extractions, isolated vs contiguous teeth, single-rooted vs multirooted teeth). The statistical analysis used univariate nonparametric tests and binary multivariate logistic regressions.

RESULTS

The 346 liver transplant candidates (mean age, 53 ± 8 years; 24% women) underwent 662 routine extraction sessions involving 1,329 teeth. The 7-day dental follow-up detected no signs of postoperative wound infection (rate = 0% [95% confidence interval (CI), 0 to 0.9%]). Accordingly, the 2-week post-extraction clinical monitoring excluded symptoms of systemic infection attributable to the dental procedure. Minor complications (mild bleeding, slow healing, inflamed socket) occurred in 50 patients (rate = 14% [95% CI, 11 to 18%]) in the 3 days after extraction. Significant risk factors for minor complications were refractory ascites (P < .0001; OR = 8 [95% CI, 3 to 20]), extraction of multirooted contiguous teeth (P < 0.0001; OR = 5 [95% CI, 2.5 to 9]), and a Model for End-Stage Liver Disease score greater than 18 (P = 0.01; OR = 2.4 [95% CI, 1.2 to 5]).

CONCLUSIONS

Our study showed that routine extractions without antibiotic prophylaxis can be performed safely in liver transplant candidates, even in the presence of 1 or more non-controllable risk factors. Using atraumatic techniques, we achieved satisfactory healing of the gingiva and socket in all patients in a week, without any signs of local infection. The few minor complications were readily managed and resolved within 3 days after extraction.

Bleeding during and after dental extractions in patients with liver cirrhosis

Little is known about the prevention and management of acquired coagulopathies, such as those affecting cirrhotic patients. The objective of this analytic retrospective observational study was to evaluate patients on the liver transplant waiting list according to the following outcomes: (1) presence of unusual intraoperative bleeding (>10min after routine haemostatic procedures); and (2) presence of postoperative haemorrhagic complications. The outcomes were analysed according to clinical and laboratory variables. A total of 190 visits were performed for extraction of 333 teeth (ranging from 1 to 9 teeth per visit), with platelet count ranging from 16,000 to 216,000 and international normalized ratio (INR) below 3. Twelve cases (6.31%) had unusual intraoperative bleeding and 12 had postoperative haemorrhagic complications. All the events were controlled by local measures. Intraoperative bleeding was associated with low count of platelets (P=0.026). However, this counting could explain only 16% (adjusted R²=0.16) of the cases of bleeding (P=0.44), meaning that platelet function changes might be involved. Our results show that cirrhotic patients presenting platelet count above 16,000 and INR below 3 need no previous blood transfusion, with local measures being enough to manage haemorrhagic events.

Hospital dental practice in special patients

Dental patients with special needs are people with different systemic diseases, multiple disorders or severe physical and/or mental disabilities. A Medline search was made, yielding a total of 29 articles that served as the basis for this study, which offers a brief description of the dental intervention protocols in medically compromised patients. Dental treatment in patients with special needs, whether presenting medical problems or disabilities, is sometimes complex. For this reason the hospital should be regarded as the ideal setting for the care of these individuals. Before starting any dental intervention, a correct patient evaluation is needed, based on a correct anamnesis, medical records and interconsultation reports, and with due assessment of the medical risks involved. The hospital setting offers the advantage of access to electronic medical records and to data referred to any complementary tests that may have been made, and we moreover have the possibility of performing treatments under general anesthesia. In this context, ambulatory major surgery is the best approach when considering general anesthesia in patients of this kind.

Key words:Hospital dentistry, special patients, medically compromised patients.