Clinical Scenario

A 46‐year‐old female presents for an assessment appointment, asking you to ‘fix her mouth’ as she has difficulty chewing because her teeth are so broken down. The medical practitioner has prescribed repeated courses of antibiotics for her due to recurrent episodes of dental infection, but these have not been effective.

Structured Learning

1. The patient asks for urgent treatment as her hepatologist has advised her that the poor oral health is linked to the liver disease. Is this correct?
   • Periodontitis may act as a persistent source of oral bacterial translocation, causing inflammation and increasing cirrhosis complications
   • Furthermore, there is some evidence that severe periodontitis is associated with higher mortality in patients who have cirrhosis
2. Other than her very poor oral hygiene, why is this patient at increased risk of repeated oral infections?
   

   

   • Liver cirrhosis impairs the homeostatic role of the liver in the systemic immune response
   • Damage to the reticuloendothelial system and the reduction of hepatic synthesis of proteins involved in innate immunity impair the bactericidal ability of phagocytic cells
3. The initial phase of treatment involves removal of the infected retained roots. Why should the patient be referred to a hospital setting for this?
   • Although the cirrhosis is currently compensated, there has been a previous decompensation episode
     • Decompensated cirrhosis is defined as an acute deterioration in liver function in a patient with cirrhosis
     • Typical presenting clinical features include jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome or oesophageal variceal haemorrhage
     • These patients are at high risk of complications/mortality
   • Thrombocytopenia
     • Thrombocytopenia is the most common haematological abnormality in patients with cirrhosis
     • Often attributed to hypersplenism (increased pooling of platelets in a spleen enlarged by congestive splenomegaly secondary to portal hypertension)
     • Pathogenesis also related to decreased platelet production and increased destruction
     • Considered an indicator of advanced liver disease and poor prognosis
4. Apart from the thrombocytopaenia, why would this patient have a tendency to bleed during an oral surgical procedure?
   • Hepatic synthesis of coagulation factors might be impaired
   • Poor absorption and utilisation of vitamin K impairs the synthesis of coagulation factors II, VII, IX and X
   • Bleeding gums due to poor oral hygiene
5. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Risk of alcoholism relapse
     • Limited financial means
     • Primary carer for her 12‐year‐old daughter (husband often works away from home)
     • Availability of an adult escort
   • Medical
     • History of alcoholism (see Chapter 15.5); relapses are common in the short‐term (3 years)
     • Compensated cirrhosis (increased risk of bleeding and infection, avoid drugs metabolised in the liver)
     • Thrombocytopenia (see Chapter 11.4)
     • Anxiety/risk of triggering an acute episode in relation to the planned dental treatment, especially as injections will be required (see Chapter 15.1)
   • Dental
     • Neglected dentition/poor oral hygiene habits
     • High treatment needs
     • Uncertain degree of co‐operation in the dental setting
     • Unpredictable commitment to improved oral hygiene measures or to regular follow‐up appointments
6. The patient is extremely anxious and requests sedation or general anaesthesia for the planned dental extractions. What should you consider?
   • Sedation and general anaesthetic drugs are potentially dangerous in liver disease mainly due to impaired detoxification; this can result in encephalopathy and potentially coma
   • Halothane should be avoided; this risk is higher in obese patients, smokers, middle‐aged females and/or if a halothane has been given in the last 3 months
   • Newer agents, e.g. enflurane or sevoflurane, are less hepatotoxic
   • Relative analgesia with nitrous oxide is preferred to sedation with a benzodiazepine
   • A specialist anaesthetist is required even if general anaesthesia is unavoidable
   • It should also be noted that this patient is already taking lorazepam

7. Liver function tests, a full blood count and a clotting screen are undertaken prior to the planned dental extractions. The liver function tests and clotting screen are normal. The platelet count is 49 × 10⁹ per litre. What is your approach?
   • Contact the hepatologist/physician for advice
   • Haematological support may include the administration of vitamin K, vasopressin or platelet transfusion. This should preferentially be administered by a specialist
   • Limit the number of extractions undertaken and implement local haemostatic measures (see Chapter 11.4)
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