Liver and renal Flashcards
Diagnosis and Tx plan for:
A 50-year-old male attends your general dental practice. You take the following history:
C/O: Painful and broken tooth in upper left of his mouth
H/P/C: The tooth broke 3 days ago
Painful with cold and hot drinks
The pain lasts for about 5 minutes
It is very sensitive to touch - TTP
M/H: He reports being perfectly fit and healthy
Medications: Paracetamol for pain relief
S/H: Enjoys drinking alcohol socially
Non smoker
irreversible pulpitis
after discussing all the available options you elect to remove tooth 26.
The gentleman also has a retained root 25 which you have discussed removing.
he has only provided his consent to the removal of tooth 26 as the root is not sore.
- He wishes to keep the root as he has read it is important if you want implants.
potential medical reasons for not being able to achieve haemostasis
several
inc
- inherited/congital bleeding disorders
- medication induced
- haematological disease
- liver disease
haemstasis processs
complex, multi-stage process and impairment at any stage could result in inability to stop bleeding
inherited/congential bleeding disorders examples
haemophilia A and B
von Williebrand’s disease
medications that can inhibit haemostasis
- Antiplatelet:
- Aspirin, Clopidogrel, Prasugrel or Ticagrelor
- Anticoagulants:
- Heparin, warfarin, apixaban
- Low Molecular Weight Heparin
- New or Novel Oral Anticoagulant or Target-specific anticoagulants
- Coumarin Anticoagulants
Other drugs:
- Side effect of chemotherapy agents in the management of malignancy. effect bone marrow; lower platelet count
- HIV or other diseases where the bone marrow is suppressed by the agents used
- Antimicrobials: Rifampin
- Anti - seizure medications: Phenytoin, Valproic acid
- Haloperidol
- Quinine (malaria)
5 commonly known haemostatic inhibiting medication
Antiplatelet:
- Aspirin, Clopidogrel, Prasugrel or Ticagrelor
Anticoagulants:
- Heparin, warfarin, apixaban
Low Molecular Weight Heparin
New or Novel Oral Anticoagulant or Target-specific anticoagulants
Coumarin Anticoagulants
haematological diseases that can affect haemostasis
leukaemia
immune throbocytopenia purpura (ITP)
myeloma
infections that can affect haemostasis
viral infections e.g. HIV, Hep C
which hepatits infections cause the most concern with haemostasis
B and C - worried
A not as worried
5 types of liver diseases that can inhibit haemostasis
alcoholic liver disease
liver cirrhosis
hepatitis B or C infection
primary biliary cirrhosis
hepatocellular carcinoma
acute liver disease is
autoimmune primary biliary cirrhosis
chronic liver diseases occurs in
stages
what occurs as result of liver disease
Changes in both the qualitative and quantitative coagulation factors
- Impaired liver function has an impact upon the hepatic synthesis of clotting factors and proteins involved in the fibrinolytic system
- including the vitamin K dependent coagulation proteins (II, VII, IX, X).
vit K dependent clotting factors
II
VII
IX
X
what clotting factor is the most concern for liver disease
VII
prolongs PT
shortest half life - quickest to go
what can occur to blood cells as a result of liver disease
thrombocytopenia and thromobocythaemia
various mechanisms
- Splenic sequestration (old platelets -> macrophages in spleen)
- Impaired hepatic synthesis and / or increased degradation of thrombopoietin by platelets sequestered in the congested spleen (change in portal circulation so take out premature platelets -> organ damage)
alchohol impact on haemostasis
can have a direct effect - suppress bone marrow and thus impair production of cells
need to disclose truthfully
renal disease impact on haemostasis
abnormalities in platelet function in renal disease and these are independent of thrombocytopenia.
This is poorly understood on the whole but there may well be defects in platelet adhesion, secretion and storage as a result uraemia
7 stages of managing haemorrhage in GDP
- Apply pressure to the socket +/- LA soaked guaze.
- Pack the socket with a suitable adjuvant material such as oxidised cellulose or a collagen sponge
- Suture the surgical site
- Re-evaluate the medical history
- If available, you could consider a tranexamic mouthwash
- Cautery – Bipolar/ Silver nitrate sticks.
- Bone wax
consider phoning your local oral surgery or Oral and Maxillofacial Department.
- rural -> contact your local A and E department if there is no OMFS or oral surgery unit.
Re-eval MHx – not disclosed or not diagnosed?
He tells you that his platelets were measured as 50 x 109/L. The doctors think this is the reason why you could not achieve haemostasis following the tooth extraction.
The patient also tells you that he has now been referred to a Gastroenterology clinic.
He asks you, “Why are my platelets reduced and why have I been referred to the gastroenterology clinic?”
not in our scope of practice to discuss this - he should discuss with his GDP
can tell pt
- platelets are reduced - likely had impact on his ability to stop bleeding
- however, in isolation platelets levels greater than 50 x 109/L should still be a safe level to achieve haemostasis following a single uncomplicated tooth extraction
- probable that there may other features affecting coagulation
encourage to attend medical appointment
keep us informed of updates of medical situation to ensure dental care can be planned appropriately
- unable to provide any operative care until he has been fully assessed
platelet count ranges
A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia.
- 50 x 109/L – low platelet count; cut of for secondary care Tx
Above 50 – achieve haemostasias for single uncomplicated extraction
- But if multiple extractions à problems likely
