Dental examination of the liver patient

¨ Dupuytren’s contracture, a condition in which the ring and little fingers are held flexed when the hand is held passive due to thickened palmar fascial tissue

¨ Palmar erythema

¨ The fingers may be clubbed

¨ The fingernails may have a whitish colouration (leuconychia)

¨ If the hands are held outstretched in front of the patient a marked flapping tremor may be noted - 'liver flap' in severe liver decompensation.

¨ Oedema (secondary to hypoproteinaemia) may lead to ascites (fluid in the abdomen leading to distension) or ankle oedema. The commonest cause of the latter however is likely to be cardiovascular.

¨ Itching may produce scratch marks on the skin. The itching occurs due to deposition of bile salts in the skin

¨ The patient may be jaundiced

¨ Gynaecomastia (enlarged breast tissue in the male) may occur due to increased circulating oestrogen levels. This is also said to be responsible for the palmar erythema mentioned earlier

¨ Spider naevi (numerous thin, tortuous blood vessels emanating from a central arteriole) may occur on the face, neck, upper chest and back (said to be within the distribution of the superior vena cava).

¨ Parotid enlargement (sialosis) may be seen in cases of cirrhosis but this is due to the associated alcohol intake rather than the cirrhosis itself.

 

 

PRESCRIBING FOR PATIENTS WITH LIVER DISEASE

 

The use of any drug in a patient with severe liver disease should be discussed with the patient's physician. Hepatic impairment will lead to failure of metabolism of many drugs that can result in toxicity. In some cases dose reduction is required, other drugs should be avoided completely.

 

The anti-fungal drug Miconazole is contra-indicated if there is hepatic impairment and fluconazole requires dose reduction.

Erythromycin, Metronidazole and Tetracycline should be avoided.

 

Non-steroidal anti-inflammatory drugs increase the risk of gastro-intestinal bleeding and interfere with fluid balance and are best avoided.

Paracetomol doses should be reduced, as at high doses this drug is hepatotoxic.

 

 

Ref: British Dental Journal 26 July 2003; Volume 195, No. 2

 

                                                                                                                    

The following tell-tale signs of liver disease can be noticed with the patient in the dental chair.

Back to main page on liver disease

Factors affecting treatment under GA or sedation