Oral Surgery on the Patient with Cirrhosis

  • James Guggenheimer


The patient with cirrhosis should undergo a comprehensive dental evaluation and treatment of all active disease to reduce the risk for dental infection. This is based on the compromised immune status of these patients secondary to end-stage liver disease and when liver transplantation is being considered. As of 2012, 61% of the adults on the liver transplant wait list had primary liver diseases attributable to hepatitis C, alcoholic cirrhosis, or subsequent hepatocellular carcinoma. It is, therefore, likely that many of these patients’ lifestyles were not conducive to having had regular dental care or maintaining good oral health. Additionally, socioeconomic limitations, older age, further deterioration of dental health during the progression of their liver disease, and time constraints may indicate a need for dental extractions. Treatment concerns associated with dental surgery for patients with cirrhosis include risk of infection, coagulopathies, and appropriate use of analgesics and anesthetics, all of which will be addressed in this chapter.


Analgesia Bacterial infections Cirrhosis Dental care Dental health Hemostatic techniques Immunocompromised host Perioperative procedures Substance abuse 


  1. 1.
    National Institutes of Health Consensus Development Conference Statement. Liver transplantation-June 20-23, 1983. Hepatology. 1984;4:107S–10S.CrossRefGoogle Scholar
  2. 2.
    Svirsky JA, Saravia ME. Dental management of patients after liver transplantation. Oral Surg Oral Med Oral Pathol. 1989;67:541–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Little JW, Rhodus NL. Dental treatment of the liver transplant patient. Oral Surg Oral Med Oral Pathol. 1992;73:419–26.CrossRefPubMedGoogle Scholar
  4. 4.
    Guggenheimer J, Mayher D, Eghtesad B. A survey of dental care protocols among U.S. transplant centers. Clin Transplant. 2005;19:15–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Kim WR, Smith JM, Skeans MA, Schladt DP, Schnitzler MA, Edwards EB, et al. OPTN/SRTR 2012 annual data report: liver. Am J Transplant. 2014;14:69–96.CrossRefPubMedGoogle Scholar
  6. 6.
    Douglas LR, Douglass JB, Sieck JO, Smith PJ. Oral management of the patient with end-stage liver disease and the liver transplant patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86:55–64.CrossRefPubMedGoogle Scholar
  7. 7.
    Bloom B, Simile CA, Adams PF, Cohen RA. Oral health status and access to oral health care for U.S. adults aged 18–64: National Health Interview Survey, 2008. Vital & Health Statistics – Series 10: data from the National Health Survey. 2012; July 253:1–22.Google Scholar
  8. 8.
    Novacek G, Plachetzky U, Pötzi R, Lentner S, Slavicek R, Gangl A, et al. Dental and periodontal disease in patients with cirrhosis-role of etiology of liver disease. J Hepatol. 1995;22:576–82.CrossRefPubMedGoogle Scholar
  9. 9.
    Guggenheimer J, Eghtesad B, Close JM, Shay C, Fung JJ. Dental health status of liver transplant candidates. Liver Transpl. 2007;13:280–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Helenius-Hietala J, Meurman JH, Höckerstedt K, Lindqvist C, Isoniemi H. Effect of the aetiology and severity of liver disease on oral health and dental treatment prior to transplantation. Transpl Int. 2012;25:158–65.CrossRefPubMedGoogle Scholar
  11. 11.
    Guggenheimer J, Eghtesad B, Stock DJ. Dental management of the (solid) organ transplant patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:383–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Burling TA, Ziff DC. Tobacco smoking: a comparison between alcohol and drug abuse inpatients. Addict Behav. 1988;13:185–90.CrossRefPubMedGoogle Scholar
  13. 13.
    Ojima M, Hanioka T. Destructive effects of smoking on molecular and genetic factors of periodontal disease. Tob Induc Dis. 2010;8:4–8.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Metsch LR, Crandall L, Wohler-Torres B, Miles CC, Chitwood DD, McCoy CB. Met and unmet need for dental services among active drug users in Miami, Florida. J Behav Health Serv Res. 2002;29:176–88.CrossRefPubMedGoogle Scholar
  15. 15.
    D’Amore MM, Cheng DM, Kressin NR, Jones J, Samet JH, Winter M, et al. Oral health of substance-dependent individuals: impact of specific substances. J Subst Abuse Treat. 2011;41:179–85.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Cheney CP, Goldberg EM, Chopra S. Cirrhosis and portal hypertension. In: Friedman LS, Keefe EB, editors. Handbook of liver disease. 3rd ed. Philadelphia: Saunders; 2012.!/browse/book/3-s2.0-C20100692406. Accessed 24 Aug 2016.
  17. 17.
    Helenius-Hietala J, Åberg F, Meurman JH, Isoniemi H. Increased infection risk postliver transplant without pretransplant dental treatment. Oral Dis. 2013;19:271–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Guggenheimer J, Close JM, Eghtesad B, Shay C. Characteristics of oral abnormalities in liver transplant candidates. Int J Organ Transpl Med. 2010;1:107–13.Google Scholar
  19. 19.
    Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012;102:e77–83.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Iruzubieta P, Crespo J, Fábrega E. Long-term survival after liver transplantation for alcoholic liver disease. World J Gastroenterol. 2013;19:9198–208.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Fleetwood VA, Hertl M, Chan EY. Liver transplantation to the active smoker: transplant provider opinions and how they have changed: transplantation in smokers: a survey. J Gastrointest Surg. 2015;19:2223–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Siqueira JF, Rôças IN. Microbiology of endodontic infections. In: Hargreaves KM, Berman LH, Rotstein I, editors. Cohen’s pathways of the pulp. 11th ed. St Louis: Elsevier; 2016.!/content/book/3-s2.0-B9780323096355000336. Accessed 8 Sept 2016.
  23. 23.
    Fiorello FJ. Dental management of patients with end-stage liver disease. Dent Clin N Am. 2006;50(4):563–90.CrossRefGoogle Scholar
  24. 24.
    Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015;41:1116–31.CrossRefPubMedGoogle Scholar
  25. 25.
    Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med. 2011;365:147–56.CrossRefPubMedGoogle Scholar
  26. 26.
    Perdigao JP, de Almeida PC, Mota MR, Soares EC, Alves AP, Sousa FP. Postoperative bleeding after dental extraction in liver pretransplant patients. J Oral Maxillofac Surg. 2012;70:e177–84.CrossRefPubMedGoogle Scholar
  27. 27.
    Helenius-Hietala J, Åberg F, Meurman JH, Nordin A, Isoniemi H. Oral surgery in liver transplant candidates: a retrospective study on the delayed bleeding and other complications. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;121:490–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005;45:1413–25.CrossRefPubMedGoogle Scholar
  29. 29.
    Gaby M. Absorbable hemostatic agents. Am J Health Syst Pharm. 2006;63:1244–53.CrossRefGoogle Scholar
  30. 30.
    Marco CA, Nagel J, Klink E, Baehren D. Factors associated with self-reported pain scores among ED patients. Am J Emerg Med. 2012;30:331–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions. Translating clinical research to dental practice. J Am Dent Assoc. 2013;144:898–908.CrossRefPubMedGoogle Scholar
  32. 32.
    Drugs for pain. Med Lett Drugs Ther. 2013;11:31–42.Google Scholar
  33. 33.
    Dwyer JP, Jayasekera C, Nicoli A. Analgesia for the cirrhotic patient: a literature review and recommendations. J Gastroenterol Hepatol. 2014;29:1356–60.CrossRefPubMedGoogle Scholar
  34. 34.
    Moore PA. Bupivacaine: a long-acting local anesthetic for dentistry. Oral Surg Oral Med Oral Pathol. 1984;58:369–74.CrossRefPubMedGoogle Scholar
  35. 35.
    Marcaine. FDA prescribing information. Accessed 8 Dec 2015.

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of Diagnostic SciencesUniversity of Pittsburgh School of Dental MedicinePittsburghUSA

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