Oral Surgical Treatment of Patients With Chronic Liver Disease: Assessments of Bleeding and Its Relationship With Thrombocytopenia and Blood Coagulation Parameters

doi:10.1016/j.joms.2016.08.033

Journal of Oral and Maxillofacial Surgery

Volume 75, Issue 1, January 2017, Pages 28-34

https://doi.org/10.1016/j.joms.2016.08.033 Get rights and content

Purpose

Cirrhotic patients awaiting liver transplantation require eradication of infectious oral foci to prevent septic episodes after transplantation; however, cirrhosis can hinder hemostasis and can result in severe bleeding. The present study assessed the bleeding risk factors connected with the clinical history of these patients and the characteristics of the extractions.

Materials and Methods

We retrospectively analyzed 1183 extractions in 318 patients, including 47 with severe end-stage liver disease who were outside of our intention-to-treat bracket (ie, platelet count [PLT] >40 × 10³/μL and international normalized ratio [INR] <2.5). Follow-up examinations included inspection of the oral cavity on the first, third, and seventh days, with reparatory surgery in the case of severe bleeding. Continuous variables were compared using the Mann-Whitney U and Kruskal-Wallis tests, and categorical variables were compared using Fisher's exact test. Binary logistic regression analysis was also performed.

Results

Within the intention-to-treat bracket, 1 of the 271 patients (0.4%) required surgical repair. The bleeding rate for an INR of 2.5 or more was significantly greater than that for a PLT of 40 × 10³/μL or less (4 of 10 [40%] versus 2 of 34 [6%]; P = .02]. All 3 patients with both an INR of 2.5 or more and a PLT of 40 × 10³/μL or less exhibited severe bleeding. No significant association between the occurrence of bleeding with either liver disease etiology or the number of molars extracted was found. No patient required hospitalization.

Conclusions

Patients with a PLT greater than 40 × 10³/μL and an INR of less than 2.5 can be considered relatively low-risk patients. However, an INR of 2.5 or more and, to a minor degree, a PLT of 40 × 10³/μL or less represent significant risk factors.

Section snippets

Study Population

The study population was derived from 1,135 patients referred to the Oral Surgery Section by the Liver Transplant Center from June 1, 2013 to June 1, 2015, as a part of the procedure track for candidates to receive a liver transplant. All patients underwent a preliminary visit to assess the following parameters of their oral cavity: hygiene, missing elements, and the presence of caries, periodontal disease, root residue, and osteolysis. Of the 1,135 patients, 318 (28%) required 1 or more tooth

Results

Of the 318 patients in our study, 271 (85%) met the intention-to-treat conditions. The remaining 47 patients (15%) required urgent surgery despite the presence of 1 or 2 presumed risk factors (PRFs) because of an imminent transplant. Of the 47 patients, 34 had a PTL of 40 × 10³/μL or less, 10 had an INR of 2.5 or more, and 3 had both a PTL of 40 × 10³/μL or less and an INR of 2.5 or more.

In our analysis, the liver diseases were grouped as follows. Group 1 included postalcoholic cirrhosis

Discussion

Our data analysis evidenced a very satisfactory outcome for extractions in patients awaiting liver transplantation. The overall severe BR was 3.1% (10 of 318) per patient and 1% (12 of 1183) per extraction. These rates included patients with an INR as high as 2.7 and a PLT as low as 25 × 10³/μL.

Our findings support the validity of our intention-to-treat procedure, which requires a PLT greater than 40 × 10³/μL and an INR less than 2.5, before proceeding with tooth extraction. Patients who

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Cited by (27)

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis
2022, Journal of Hepatology
Citation Excerpt :
Procedures associated with a low risk (i.e., ≤1.5%) and a high risk (>1.5%) of bleeding are reported in Table 2 (47,48,51,53,54,56,75–81). Overall, in stable patients with cirrhosis, diagnostic endoscopic procedures (e.g., gastroscopy or colonoscopy with mucosal biopsies), thoracentesis, paracentesis, trans-oesophageal echocardiography, transjugular liver biopsy and hepatic venous pressure gradient measurement, are mainly associated with a low risk of bleeding, and the occurrence of bleeding episodes has not been related to either INR values or degree of thrombocytopenia (reviewed in61,80) (Table 3).45,47–56,58,60,66,68,76–79,81–103 Percutaneous ablation of hepatocellular carcinoma is another procedure where the risk of bleeding is considered low, although in the largest series reporting the occurrence of haemorrhagic complications (0.5% in 1,834 procedures), median platelet count was 140 × 109/L and patients with a pre-procedural platelet count <50 × 109/L received 10 units of packed platelets as prophylaxis.53
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
Assessment of laboratory tests and intraoperative bleeding in patients with liver cirrhosis undergoing tooth extractions
2022, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
The objective of this study was to quantify intraoperative bleeding in patients with cirrhosis and correlate it with clinical characteristics and laboratory coagulation tests.
A case-control study was carried out with 74 patients with cirrhosis who were submitted to preoperative coagulation tests (complete blood count, platelet count, prothrombin time/international normalized ratio, thrombin time, activated partial thrombin time, platelet aggregation, fibrinogen, protein C, protein S, antithrombin, and von Willebrand factor level and activity). The levels of nitrogen compounds that can affect the platelet function were determined in saliva and blood by using automated enzymatic-colorimetric assays.
Patients with cirrhosis had changes in almost all coagulation tests. The average volumes of intraoperative bleeding and blood lost per minute in the study group (5.36 mL/min and 0.19 mL/min, respectively) were greater than those in the control group (3.05 mL/min and 0.11 mL/min, respectively; P < .05). In the control group, ascites (P = .012) and presence of periapical lesion (0.034) were positively correlated with bleeding (mL/min). With regard to coagulation tests and nitrogen compounds, only a positively moderate correlation with the platelet aggregation test was observed.
No patients had hemorrhagic events and it was not possible to correlate a greater amount of bleeding with coagulation tests or nitrogen compounds in the study group.
Treatment of bleeding in patients with liver disease
2021, Journal of Thrombosis and Haemostasis
Patients with cirrhosis frequently have complex alterations in their hemostatic system. Although routine diagnostic tests of hemostasis in cirrhosis (platelet count, prothrombin time, fibrinogen level) are suggestive of a bleeding tendency, it is now widely accepted that these tests do not reflect hemostatic competence in this population. Rather, patients with cirrhosis appear to have a rebalanced hemostatic system with hypercoagulable elements. Therefore, routine correction of hemostasis laboratory values, for example by fresh frozen plasma or platelet concentrates, with the aim to avoid spontaneous or procedure‐related bleeding is not indicated as is outlined in recent clinical guidance documents. However, little guidance on how to manage patients with cirrhosis that are actively bleeding is available. Here we present three common bleeding scenarios, variceal bleeding, post‐procedural bleeding and bleeding in a critically ill cirrhosis patient, with specific management suggestions. As patients with cirrhosis generally have adequate hemostatic competence and as bleeding complications may be unrelated to hemostatic failure, prohemostatic therapy is not the first line of management in bleeding patients with cirrhosis, even in the presence of markedly abnormal platelet counts and/or prothrombin times. We provide a rationale for the restrictive approach to prohemostatic therapy in bleeding patients with cirrhosis.
Risk of bleeding during oral surgery in patients with liver cirrhosis: A systematic review
2021, Journal of the American Dental Association
Citation Excerpt :
It should also be emphasized that efficient hemostasis requires only 20% through 50% of the normal level of most procoagulants.30 Perhaps it would be more prudent to avoid transfusions before dental procedures, as this approach does not benefit the patient, increases the cost of treatment for the patient, and exposes the patient to several adverse effects (for example, risk of experiencing infectious agent transmission and developing reactive thrombocytopenia).14,16,20,39,41,42 Results from our systematic review are supported with strong evidence.
The liver is responsible for the production of almost all coagulation factors, but does this indicate a risk of developing unusual bleeding in patients with liver cirrhosis during dental surgery?
In this systemic review, the authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and performed a search of PubMed, Latin American and Caribbean Health Sciences Literature, Web of Science, Scopus, and Cochrane databases.
Seven studies met the inclusion criteria. The sample sizes ranged from 23 through 318 participants, number of extracted teeth ranged from 62 through 1,183, platelet count ranged from 16,000 through 216,000 per cubic milimeter, and the international normalized ratio was less than 4. The prevalence of hemorrhagic events in the studies ranged from 0% through 8.9%, and almost all were controlled with local hemostatic measures.
During dental treatment, patients with liver cirrhosis have a low bleeding risk in spite of the decreased number of platelets and increased international normalized ratio.
Is It Safe to Remove Teeth in Liver Transplant Patients Without Antibiotics? A Retrospective Study of 346 Patients
2019, Journal of Oral and Maxillofacial Surgery
Eradication of oral infectious foci is essential for liver transplant candidates. The main issue is whether antibiotic prophylaxis is necessary for all dental extractions despite the possible fostering of resistant bacteria. To overcome the scarcity of evidence-based data, our study analyzed the background and outcomes of a large number of routine extractions performed in our institution without antibiotic prophylaxis in patients with different liver pathologies.
In this retrospective cohort study, the outcome of interest was the occurrence of local infections and minor complications during the 7-day follow-up period after extraction; the predictors were the demographic and clinical variables of the patients (age, gender, liver pathology, Model for End-Stage Liver Disease score, international normalized ratio) and the extraction variables (single vs multiple extractions, isolated vs contiguous teeth, single-rooted vs multirooted teeth). The statistical analysis used univariate nonparametric tests and binary multivariate logistic regressions.
The 346 liver transplant candidates (mean age, 53 ± 8 years; 24% women) underwent 662 routine extraction sessions involving 1,329 teeth. The 7-day dental follow-up detected no signs of postoperative wound infection (rate = 0% [95% confidence interval (CI), 0 to 0.9%]). Accordingly, the 2-week post-extraction clinical monitoring excluded symptoms of systemic infection attributable to the dental procedure. Minor complications (mild bleeding, slow healing, inflamed socket) occurred in 50 patients (rate = 14% [95% CI, 11 to 18%]) in the 3 days after extraction. Significant risk factors for minor complications were refractory ascites (P < .0001; OR = 8 [95% CI, 3 to 20]), extraction of multirooted contiguous teeth (P < 0.0001; OR = 5 [95% CI, 2.5 to 9]), and a Model for End-Stage Liver Disease score greater than 18 (P = 0.01; OR = 2.4 [95% CI, 1.2 to 5]).
Our study showed that routine extractions without antibiotic prophylaxis can be performed safely in liver transplant candidates, even in the presence of 1 or more non-controllable risk factors. Using atraumatic techniques, we achieved satisfactory healing of the gingiva and socket in all patients in a week, without any signs of local infection. The few minor complications were readily managed and resolved within 3 days after extraction.
Direct Oral Anticoagulants and Medical Comorbidities in Patients Needing Dental Extractions: Management of the Risk of Bleeding
2019, Journal of Oral and Maxillofacial Surgery
The purpose of this study was to measure the frequency of bleeding during and after tooth extraction in patients exposed to direct oral anticoagulants (DOACs) and identify risk factors for prolonged or excessive bleeding.
This retrospective cohort study involved 100 patients who underwent tooth extractions according to the European Heart Rhythm Association protocol: continuation of DOAC therapy for extractions of up to 3 teeth in the same session performed at the (presumed) time of DOAC trough concentration. We respected an interval of at least 4 hours between extraction and last DOAC intake. The outcome of interest was incidence of mild, moderate, and severe bleeding during the intervention and in the 7-day follow-up period. Data analysis considered the presence of comorbidities as the primary predictor for bleeding; additional predictors were age, gender, type of comorbidity, indication for DOAC therapy, DOAC agent, and extraction of contiguous teeth.
Of the patients, 64 had comorbidities (diabetes in 50%). The distributions of demographic, clinical, and dental variables were similar for patients with and without comorbidities. We observed 4 bleeding episodes (1 moderate episode 1 hour after the extraction and 3 mild episodes the day after the extraction) in the comorbidity group and none in the non-comorbidity group (4 of 64 vs 0 of 36, P = .29; overall bleeding rate, 4 of 100). The factor significantly triggering bleeding in patients with comorbidity was extractions of couples and triplets of multirooted teeth (P = .004).
Tooth extractions in patients with comorbidities taking DOACs may be safely managed as long as they are performed at least 4 hours after the last DOAC intake and do not involve 2 or 3 contiguous premolars and molars.

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Dentoalveolar surgeryOral Surgical Treatment of Patients With Chronic Liver Disease: Assessments of Bleeding and Its Relationship With Thrombocytopenia and Blood Coagulation Parameters

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Study Population

Results

Discussion

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Oral Maxillofac Surg

Clin Liver Dis

J Hepatol

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Dental health status of liver transplant candidates

Liver Transplant

Increased infection risk postliver transplantation without pretransplant dental treatment

Oral Dis

Effect of aetiology and severity of liver disease on oral health and dental treatment prior to transplantation

Transpl Int

Organ transplantation—assessment of dental procedures

Oral Biosci Med

Necessity of surgical dental foci treatment prior to organ transplantation and heart valve replacement

Clin Oral Investig

Chirurgia Stomatologica Biologicamente Guidata. Approccio al paziente. Linee guida e protocolli operativi

Dentoalveolar surgery
Oral Surgical Treatment of Patients With Chronic Liver Disease: Assessments of Bleeding and Its Relationship With Thrombocytopenia and Blood Coagulation Parameters