Liver disease
The liver is the largest organ in the body and is involved with
almost all of the biochemical pathways that per-mit growth, ght
disease, supply nutrients, provide energy and carry out detoxication. Liver disease and its consequences can pose multiple problems in dental practice.
Anatomy
The liver gains 70% of its blood supply from the portal vein
and 30% from the hepatic artery. Almost all the nutrients
and drugs absorbed from the stomach and intestine are
directed to the liver for processing (Fig. 8.1). This so-called
rst-pass metabolism can be avoided when drugs are
given intravenously (IV) or sublingually.
Epidemiology
Liver disease is relatively uncommon in the western
world. About 600 liver transplants are carried out per
year for end-stage liver disease in the UK. Two aspects
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Liver
Bile duct
Stomach
Gall bladder
Hepatic portal
vein
Pancreas
Small bowel
(duodenum)
Aetiology
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Clinical features
Clinical features
The general features of liver disease that may be detected
in dental practice include:
Jaundice. This is a yellow pigmentation of the skin,
sclerae and oral mucosa due to deposition of bilirubin
in tissues. It is detectable when the bilirubin is above
3060 mmol/L.
Spider naevi. These small arterial dilations may be
detected in the skin of the face and neck.
Palmar erythema. Redness of the palms of the hand.
Dupuytrens contracture. Fixed exion of the little and
sometimes ring nger due to thickening of the
palmar fascia (Fig. 8.2).
Finger clubbing. Loss of the normal angle at the bed of
the nails.
Multiple bruises. These occur on areas exposed to
trauma due to the underlying clotting defect.
Delayed healing. This is due to the decreased synthesis
of protein and immunoglobulins.
Confusion. This may occur in severe cases due to
unmetabolised toxins reaching the CNS.
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Hepatitis
This is inammation of the liver which may be acute or
chronic, causing enlargement, tenderness and deranged
function. Viral infection with hepatitis A, B, C, D or E is
the most common cause of inammation of the liver and
can present a signicant cross-infection risk as well as
liver damage. Other viruses, including CMV, EBV, Varicella, Rubella, Toxoplasma and Coxsackie virus and HIV
can also cause hepatits (cf. infectious disease section).
Alcoholic hepatitis can occur even with moderate intake
in susceptible individuals. In rare circumstances acute
hepatitis can lead to hepatic failure and death, for example
paracetamol overdose.
Cirrhosis
This results from necrosis of liver cells followed by brosis
and nodule formation. This causes disruption of blood
ow through the liver and loss of function. The diagnosis
is a histological one and requires a biopsy although the
severity of cirrhosis is determined clinically.
If the cirrhosis is asymptomatic the long-term prognosis
is usually good, provided the causative factor is under
control. Alcohol-induced cirrhosis has a worse prognosis.
Patients must abstain from alcohol whatever the cause of
their cirrhosis. In long-standing cases there is a small risk
of developing hepatocelluar carcinoma.
The liver has a huge reserve capacity and the ability to
regenerate so the effect of hepatitis or cirrhosis depends
on whether the liver is compensated (coping with reduced
capacity) or decompensated (not coping with reduced
capacity). Patients with decompensated disease are at a
greater risk from any intervention, including dental treatment. Signs of decompensated disease include jaundice,
ascites and neurological impairment.
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Renal disease
Table 8.1
Drugs to be avoided or altered during dental treatment of
patients with liver disease.
Drug name
Paracetamol
NSAIDs
Amoxicillin
Metronidazole
Clindamycin
Tetracycline
Miconazole
Lignocaine
Halothane
Midazolam
Renal disease
The kidneys receive approximately 25% of the cardiac output per
minute normally producing 12 litres of urine per day. Most
drugs along with other waste products are excreted by the kidneys
and they have an important role in homoeostasis and hormone
synthesis.
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Epidemiology
Renal disease is common within the population. The incidence of chronic renal failure increases with age; it is more
common in men and those of Asian or Afro-Caribbean
origin. 1700 renal transplants were carried out in the UK
in 2004. There are about 20 000 people in the UK with a
functioning renal transplant.
Aetiology
Diabetes is the main cause of end-stage renal failure
(ESRF) accounting for 40% of cases. The kidneys may also
be damaged by hypertension, ascending infection and
immunological mechanisms.
Three aspects of renal disease are most important in
relation to dentistry:
1. Renal failure
2. Dialysis
3. Transplantation.
Renal failure
This is said to occur when the kidneys fail to maintain
excretory function as a result of a reduced glomerular ltration rate. This may be acute or chronic.
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Aetiology may be pre-renal (poor perfusion), renal (glomerulonephritis, SLE, acute tubular necrosis) or post-renal
(obstruction).
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Table 8.2
Drugs to be avoided or altered during dental treatment of
patients with renal failure.
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Drug name
Paracetamol
NSAIDs
Amoxicillin
Metronidazole
Clindamycin
Tetracycline
Miconazole
Lignocaine
Halothane
Midazolam
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