DR.

AHMED AL-BAGHDADI

Liver diseases
A) Functions of liver
1. Metabolism: The liver is involved in various metabolic processes, including:
- Carbohydrate metabolism: It helps regulate blood glucose levels by storing excess glucose as
glycogen and releasing it when needed.
- Lipid metabolism: It synthesizes, stores, and breaks down fats, including cholesterol and
triglycerides.
- Protein metabolism: It synthesizes plasma proteins, such as albumin and clotting factors, and
converts ammonia into urea for excretion.
- Drug metabolism: It detoxifies and metabolizes drugs, alcohol, and other harmful substances.
2. Detoxification: The liver plays a crucial role in removing toxins and waste products from the body,
including:
- Detoxification of drugs, alcohol, and environmental toxins.
- Conversion of ammonia (a byproduct of protein metabolism) into urea, which is then
eliminated by the kidneys.
- Processing and elimination of bilirubin, a waste product from the breakdown of old red blood
cells.
3. Bile Production: The liver produces bile, a substance necessary for the digestion and absorption of fats.
Bile is stored in the gallbladder and released into the duodenum to aid in the breakdown and absorption of
dietary fats.
4. Storage: The liver serves as a storage organ for various substances, including:
- Glycogen: It stores excess glucose as glycogen and releases it when blood sugar levels drop.
- Vitamins (such as vitamins A, D, E, and K) and minerals (such as iron and copper).
- Blood: The liver can store a certain amount of blood, acting as a blood reservoir.
5. Synthesis: The liver synthesizes several important substances, including:
- Clotting Factors: It produces various clotting factors necessary for the proper clotting of blood.
- Albumin: It synthesizes albumin, a major protein in the blood that helps maintain osmotic
pressure and transport substances.
- Cholesterol: It produces cholesterol, which is essential for the formation of cell membranes and
the synthesis of certain hormones.
6. Immune Function: The liver plays a role in the immune system by:
- Removing bacteria, viruses, and other pathogens from the blood.

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Liver diseases
- Producing immune factors and proteins that help fight infections and regulate immune
responses.
7. Storage of Vitamin B12: The liver stores vitamin B12, which is necessary for the production of red
blood cells and the proper functioning of the nervous system.

B) Common hepatic diseases

1. Cholecystectomy:
- Definition: Cholecystectomy refers to the surgical removal of the gall bladder. Gall bladder stones
(cholelithiasis) and biliary dyskinesia are common reasons for this procedure.
- Causes: Gall bladder stones may form due to the crystallization of cholesterol or bilirubin. Biliary
dyskinesia involves impaired gall bladder motility.
- Signs and Symptoms: Patients may experience abdominal pain, bloating, nausea, and vomiting.
Jaundice can occur if there is obstruction of the bile duct.
2. Infective Hepatitis (A, B, C, D, and E):
- Definition: Infective hepatitis is inflammation of the liver caused by viral infections.
- Causes:
Hepatitis A: Transmitted through contaminated food or water (fecal-oral route)
Hepatitis B: Transmitted through blood, body fluids, or sexual contact.
Hepatitis C: Transmitted through blood-to-blood contact, often associated with intravenous drug
use or unsafe medical practices (blood-borne infections)
Hepatitis D: Requires co-infection with hepatitis B.
Hepatitis E: Transmitted through contaminated (fecal-oral route), often seen in developing
countries.
- Signs and Symptoms: Symptoms may include fatigue, jaundice, dark urine, abdominal pain, loss of
appetite, and nausea.
3. Liver Cirrhosis:
- Definition: Liver cirrhosis is a late-stage liver disease characterized by irreversible scarring of the
liver tissue.
- Causes:
a) Alcoholic Liver Disease: Chronic alcohol abuse leads to liver damage, mainly through the formation
of acetaldehyde.
b) Viral Hepatitis: Long-term infection with hepatitis B or C viruses can cause cirrhosis.

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Liver diseases
c)Non-Alcoholic Fatty Liver: Accumulation of fat in the liver, often associated with obesity, diabetes
mellitus, glucocorticoid use, hepatitis C, or certain medications like methotrexate.
- Signs and Symptoms:
a) Jaundice: Yellowing of the skin and eyes due to elevated bilirubin levels (>2-3mg/l).
b) Ascites: Accumulation of fluid in the peritoneal cavity, leading to abdominal distension and
increased weight. Diuretics or peritoneal dialysis may be used for treatment.
c) Fatigue, itching, and dry skin can be observed.
d) Swelling in the legs may occur due to fluid retention.
e) Portal Hypertension: Increased blood pressure in the portal vein system, often resulting in the
development of esophageal varices, which can cause severe pain and lead to hematemesis and anemia.
Causes of Itching (pruritus) in patients with liver cirrhosis.
1. Bile Salt Accumulation: bile salts can deposit in the skin
2. Elevated Histamine Levels:
3. Skin Dryness: decreases in production and secretion of oils that help keep the skin
moisturized. Dry skin can become itchy and prone to irritation.
4. Toxins and Metabolic Waste Products: liver's ability to detoxify substances is
compromised. Accumulation of toxins and metabolic waste products in the bloodstream can
trigger itching.
5. Neurological Factors: Liver dysfunction can affect the nervous system, leading to
altered sensory perception and increased sensitivity to itching sensations.
6. Secondary Conditions: Liver cirrhosis is often associated with other health
conditions, such as kidney dysfunction or diabetes, which can independently cause itching.
4. Hepatosplenomegaly:
- Causes: Hepatosplenomegaly refers to the enlargement of the liver and spleen and can be secondary to
portal hypertension.
- Signs and Symptoms: Patients may present with abdominal pain, fullness, and an enlarged liver and
spleen on examination.

C) Dental consideration in management of patient with liver

disease
1. Vitamin K Deficiency:
- Cause: Liver disease can lead to impaired synthesis of clotting factors, including those dependent on
vitamin K. Additionally, liver disease may hinder the absorption of dietary vitamin K.

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- Function of Vitamin K: Vitamin K is essential for the synthesis of clotting factors in the liver. It plays a
crucial role in blood clotting and coagulation.
- Bleeding Problems: Patients with liver disease may have an increased risk of bleeding due to decreased
clotting factor production, leading to prolonged bleeding after dental procedures. It is important to assess
the patient's clotting status and consider appropriate measures to prevent bleeding complications.
2. Transmission of Infections:
- Causes in Viral Hepatitis (B and C): Hepatitis B and C are blood-borne infections that can be transmitted
through contact with infected blood or body fluids. Dental procedures involving potential exposure to
blood or saliva can pose a risk of transmission. Standard precautions, including proper sterilization and
barrier techniques, should be strictly followed to minimize the risk of transmission.
3. Drug Biotransformation:
- Liver disease can affect the metabolism and clearance of medications. Impaired liver function can lead to
altered drug metabolism, potentially resulting in prolonged drug effects or increased toxicity. Dentists
should be cautious when prescribing medications and consider adjusting dosages or selecting alternative
drugs to avoid adverse effects.
hepatotoxic drugs:
1. Acetaminophen (paracetamol): in excessive doses
2. NSAIDs: such as ibuprofen, naproxen, and diclofenac,
3. Antibiotics: isoniazid, rifampin, and certain macrolides (e.g., erythromycin
4. Antifungal medications: ketoconazole and fluconazole,
5. Antiepileptic drugs: valproic acid, carbamazepine, and phenytoin
6. Statins: atorvastatin and simvastatin

4. Anemia:
- Anemia, a condition characterized by a decrease in the number of red blood cells or hemoglobin levels,
can be associated with liver disease. The liver plays a role in the production and recycling of red blood
cells. Anemia can contribute to fatigue, weakness, and poor healing. Dental procedures may further
exacerbate anemia-related symptoms. It is important to identify and manage anemia in patients with liver
disease before dental interventions.
5. Esophageal Varices:
- Portal hypertension, a complication of liver cirrhosis, can lead to the development of esophageal varices.
These are dilated blood vessels in the esophagus that are prone to rupture and severe bleeding. Dental
procedures that involve manipulation of the oral tissues can potentially increase the risk of variceal
bleeding. Dentists should be aware of the patient's condition and coordinate with the patient's healthcare
team to minimize the risk of bleeding.
6. Heart Failure:
- Liver disease, particularly in advanced stages, can be associated with heart failure. Patients with liver
disease may have compromised cardiovascular function. Dental treatment, especially in patients with

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Liver diseases
significant comorbidities, should be carefully planned and coordinated with the patient's medical team to
ensure safe management and minimize the risk of cardiovascular complications.

D) Dental Considerations in Managing Patients with Liver

Disease:
1. Aseptic Precautions to Avoid Trans-Infection:
- Due to the increased risk of transmissible infections such as hepatitis B and C, strict adherence to aseptic
techniques is crucial. Proper sterilization of instruments, use of disposable items when possible, and
adherence to universal precautions minimize the risk of cross-contamination between patients and dental
healthcare providers.
2. Limitations for Use of Amide Local Anesthetics:
- Liver disease can affect the metabolism and clearance of medications, including local anesthetics. Amide
local anesthetics, such as lidocaine and prilocaine, are primarily metabolized by the liver. In patients with
advanced liver disease, the clearance of these medications may be impaired. Careful consideration should
be given to the selection and dosage of local anesthetics to avoid potential toxicity.
3. Guidelines for Management of Anemic Patients Applied:
- Anemia is common in patients with liver disease. Before dental procedures, it is important to assess and
manage the patient's anemia appropriately. This may involve collaboration with the patient's medical team
to optimize hemoglobin levels through iron supplementation, transfusions, or other interventions. Treating
anemia can help improve patient outcomes and reduce the risk of complications during dental procedures.
4. Restrict Use of Medications:
- Liver disease can impair drug metabolism and clearance, increasing the risk of medication-related adverse
effects. Dentists should be cautious when prescribing medications to patients with liver disease. Certain
medications, such as those metabolized by the liver or with hepatotoxic potential, may need to be avoided
or used with caution. Close communication with the patient's healthcare team is essential to ensure safe and
appropriate medication management.
5. Local Hemostatic Measures:
- Patients with liver disease may have impaired clotting function, predisposing them to bleeding
complications. Local hemostatic measures, such as the use of hemostatic agents, pressure application, and
suturing techniques, should be employed to achieve adequate hemostasis during dental procedures.
Adjunctive measures, such as the use of tranexamic acid mouthwash, may be considered to reduce
bleeding.
6. Avoid Erythromycin Antibiotics:
- Erythromycin is metabolized by the liver, and patients with liver disease may have impaired drug
metabolism. It is advisable to avoid or use erythromycin with caution in patients with liver disease to

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prevent potential drug accumulation and hepatotoxicity. Alternative antibiotics that are not primarily
metabolized by the liver may be preferred.
7. Vitamin K Supplementation in Cholecystectomy Cases:
- Cholecystectomy refers to the surgical removal of the gallbladder. In certain cases, vitamin K
supplementation may be required preoperatively. The liver is responsible for the synthesis of clotting
factors, including those dependent on vitamin K. In cholecystectomy patients, vitamin K supplementation
may help prevent bleeding complications during and after the surgery.

NOTE
 When selecting antibiotics and analgesics for patients with liver disease, it is important to consider
medications that have minimal potential for hepatotoxicity and are well-tolerated in individuals
with compromised liver function
AB ANALGESIC
1- Amoxicillin-Clavulanate:
2- Ceftriaxone: third-generation cephalosporin 1- Paracetamol): LOW DOES
3- Azithromycin: Analgesics: 2- Tramadol