Medical considerations for dental care of patients with alcohol-related liver disease

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.

Porphyromonas gingivalis as a Possible Risk Factor in the Development/Severity of Acute Alcoholic Hepatitis

Bacterial infection is frequently observed in patients with alcoholic liver disease (ALD). We examined a possible role of Porphyromonas gingivalis in the development/progression and severity of disease in patients with acute alcoholic hepatitis (AAH). Plasma specimens from 47 patients with AAH (16 moderate, Model for End‐Stage Liver Disease [MELD] score <20]; 31 severe, MELD score >20) and 22 healthy controls (HCs) were collected. Clinical, drinking history (lifetime drinking history [LTDH]), and demographic data were collected. Antibody tests for immunoglobulin (Ig) G, IgM, and IgA against two P. gingivalis strains were performed. Between‐group comparisons and within‐group association analyses were carried out. Patients with severe AAH showed significantly higher plasma levels of IgG, IgA, and IgM against two P. gingivalis strains (W83 and 33277) compared to HCs. Patients with moderate AAH also had significantly elevated anti‐P. gingivalis IgA concentrations for both strains compared to HCs. Male patients with moderate AAH showed a significant inverse association in LTDH and anti‐P. gingivalis IgM. The aspartate aminotransferase:alanine aminotransferase ratio was positively associated with IgM of both strains in male patients with moderate AAH. Female patients with severe AAH showed a significant association between MELD scores and W83 IgM. Conclusion: Antibody response to P. gingivalis in AAH is elevated. Significantly elevated plasma anti‐P. gingivalis IgG, IgA, and IgM in severe AAH provide preliminary data that P. gingivalis could be a novel risk factor in the development/severity of AAH.

Long-Term Postoperative Bleeding After Dentoalveolar Surgery in the Pretransplant Liver Failure Patient

PURPOSE

A retrospective review of a protocol-driven single institutional experience for treatment of pretransplant liver failure patients requiring dentoalveolar procedures for transplant clearance.

MATERIALS AND METHODS

Between January 2003 and June 2005, 30 liver failure patients requiring pretransplant dentoalveolar surgery at the University of Michigan Hospital were treated in the Department of Oral and Maxillofacial Surgery/Hospital Dentistry undergoing 35 total procedures. These patients were stratified preoperatively into 3 different "risk" groups (minimal, moderate, high) based on number and complexity of teeth to be extracted as well as any planned adjunctive preprosthetic procedures.

RESULTS

Analysis of variance (ANOVA) comparison of groups was conducted, as well as logistic regression analysis and 2-tailed Pearson correlation using chi2 and the Fisher exact test. The only statistically significant (P < .05) predictors of long-term postoperative bleeding were surgeon-defined "risk," the number of simple extractions, and quadrants of alveoplasty. Additional postoperative correlations were found between long-term bleeding and the need for hospital admission as well as the use of blood products for treatment. Model for end-stage liver disease (MELD), preoperative prothombin time (PT), preoperative partial thromboplastin time (PTT), preoperative international normalized ratio (INR), and preoperative platelet count were not statistically significant in predicting postoperative bleeding. Despite a more aggressive protocol for preoperative management of "high risk" patients, 5/10 (50%) experienced prolonged postoperative bleeding, with 3/5 (60%) requiring admission, while 1/5 (20%) experienced significant prolongation of their current inpatient stay. Review of the data showed that 5/9 (56%) of patients with 10 or more simple extractions developed long-term postoperative bleeding, all of whom had been classified in the "high risk" grouping. Admitted patients remained hospitalized an average of 4 days (range of 1-6 days).

CONCLUSION

Even with aggressive preoperative management, pretransplant liver failure patients requiring extraction of at least 10 teeth prior to placement on the liver transplant list are at significant risk of long-term postoperative bleeding and hospital admission for its management.

Dental management of patients with end-stage liver disease

This article presents a review of end-stage chronic liver disease (cirrhosis) with emphasis on the clinical presentation, diagnosis, and complications of cirrhosis, along with their medical and surgical management and prognosis. This article also discusses the evaluation and management of the dental patients with cirrhosis, including the implications decreased hepatic function has on drugs commonly used in dental treatment.

The management of acute dental pain in the recovering alcoholic

Although there have been many advances in our understanding of the neurophysiology of pain, the management of acute pain continues to be a challenge. When the need arises to provide adequate and effective pain management for the recovering alcoholic, the problem becomes much more complex. The clinician must provide the patient with adequate analgesia without causing a relapse. In the US, 6% to 10% of the population has attended Alcoholics Anonymous at some point, increasing the likelihood of the clinician being faced with the need to manage acute pain in a recovering alcoholic. The purpose of this article is to suggest guidelines for the management of acute dental pain in the recovering alcoholic based on current principles of acute pain management and for the treatment of pain in addicted patients.

Systemic diseases and their treatments in the elderly: impact on oral health

The lifespan of the US population is increasing, with the elderly desiring successful aging. This goal is jeopardized as multiple systemic conditions and their treatments become more prevalent with age, causing impaired systemic and oral health and influencing an older person's quality of life. To obtain successful aging, a compression of morbidity must be obtained through prevention and management of disease. This paper describes the most common systemic diseases causing morbidity and mortality in persons aged 65+ years: diseases of the heart, malignant neoplasms, cerebrovascular diseases, chronic obstructive pulmonary disease, pneumonia, influenza, diabetes mellitus, trauma, Alzheimer's disease, renal diseases, septicemia, and liver diseases. Disease prevalence and the impact of medications and other therapeutic measures used to treat these conditions are discussed. Oral sequelae are reviewed with guidelines for early detection of these deleterious consequences, considerations for oral treatment, and patient management. An understanding of the impact of systemic diseases and treatment on oral health is imperative for dental practitioners to appropriately treat and manage older patients with these conditions. With a focus on early detection and prevention, oral health care providers can improve the quality of life of this population and aid in the attainment of successful aging.