Liver disease stuff plus some haemotology stuff

Question 1

What are the potential medical reasons for inability to achieve haemostasis

Answer 1

Inherited / Congenital Bleeding Disorders:
-Haemophilia A and B
-Von Willebrand’s Disease

Medication Induced:
-Antiplatelet: Aspirin, Clopidogrel
-Anticoagulants: Heparin, Low Molecular Weight Heparin, NOACS
Coumarin Anticoagulants

Other drugs:
-Side effect of chemotherapy agents in the management of malignancy
-HIV or other diseases where the bone marrow is suppressed
-Antimicrobials: Rifampin
-Anti seizure medications: Phenytoin, Valproic acid, Haloperidol, Quinine

Haematological Disease:
-Leukaemia
-Immune Thrombocytopenia Purpura (ITP)
-Myeloma

Infections:
-Viral infections such as HIV or Hep C

Liver Disease:
-Alcoholic liver Disease
-Liver Cirrhosis
-Hepatitis B or C infection
-Primary Biliary Cirrhosis
-Hepatocellular carcinoma

Alcohol can also have a direct effect to suppress the bone marrow and thus impair the production
of cells

Question 2

What does liver disease have an affect on

Answer 2

Changes in both the qualitative and quantitative coagulation factors occur as a result of liver disease

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

Impact in production of thrombopoietin as well which could result in Thrombocytopenia or thrombocythaemia

Question 3

What is thrombocythaemia

Answer 3

blood disorder that causes a high number of blood cells called platelets to form

Question 4

What is thrombocytopenia

Answer 4

a condition that occurs when the platelet count in your blood is too low

Question 5

what are the haemostatic measures you carry out

Answer 5

1. Apply pressure to the socket +/- LA soaked guaze.
2. Pack the socket with a suitable adjuvant material such as oxidised cellulose or a collagen sponge
3. Suture the surgical site
4. Re-evaluate the medical history
5. If available, you could consider a tranexamic mouthwash
6. Cautery – Bipolar/ Silver nitrate sticks.
7. Bone wax

Question 6

What should the platelet count be to safely cary out dental treatment

Answer 6

> 50 x 10(9)/L

Question 7

What are signs of advancing liver disease

Answer 7

Skin: Jaundice, leukonychia, clubbing, palmar erythema, Dupuytren’s contracture, spider naevi

bleeding
oesophageal varices
ascites
peritonitis,
encephalopathy
hepatorenal syndrome

Question 8

What can cause liver disease

Answer 8

Infective:

Hepatitis Viruses: A,B,C and D

Non-infective:
Autoimmune – Primary Biliary Cirrhosis
Alcohol related
Non-alcoholic fatty liver disease
Haemochromatosis
Drug induced
Hepatocellular carcinoma

Question 9

What are the stages of liver disease

Answer 9

Hepatitis: Inflammation of the liver which may or may not be reversible depending on the
disease

→ Liver cirrhosis
Irreversible liver necrosis and fibrosis

→ Liver failure
Failure of normal liver function

Question 10

What is the UKELD score

Answer 10

The United Kingdom Model for End Stage Liver Disease (UKELD) is a system which predicts a person’s prognosis in chronic liver disease and is used as to guide determine the need for liver transplant

Question 11

What is minimun UKLED score for transplant

Answer 11

49

Question 12

If you were to treat a patient safely that has liver disease what specia investigations can you do

Answer 12

1. It is important to liaise with the hepatology unit to establish the medical condition and to be able to work together to ensure appropriate medical care to facilitate safe dental treatment in the correct environment
2. Blood tests: FBC, Coagulation/clotting screen (PT + ration, APTT + ratio, thrombin
   time,TCT ratio) +/- INR , LFTS , Us and Es
3. Appropriate radiographs: OPT +/- intraoral views as required, full mouth pocket chart if
   required after bloods

Question 13

what is the safest local anaesthetic drug to use, utilising an infiltration technique, for a patient with advanced liver disease and why

Answer 13

Articane

Lignocaine is fully metabolised in the liver however, only 5-10% of Articaine is processed in the
liver, the majority of the drug being metabolised in the plasma this is advantageous at is decreases the metabolic demand on the live

Question 14

When providing instructions on first line simple analgesia for a patient with liver cirrhosis, which analgesic medication should be recommended

Answer 14

paracetamol as NSAID’s can increase bleeding risk which will result in mucosal bleeding (great concern
in those with oesophageal varices)

Question 15

The liver is responsible for the production of which clotting factors involved in the coagulation cascade

Answer 15

I,II,VII, IX, X and XI

Question 16

An arteriovenous fistula is provided in which situations

Answer 16

Above the wrist for haemodialysis

Question 17

Haemophilia A is a deficiency in which factor

Answer 17

VIII

Question 18

Apixaban inhibits which factor

Answer 18

Xa

Question 19

A person with Moderate Haemophilia has what percentage of normal factor in their blood

Answer 19

1-5%

Question 20

Von Willebrand’s Type 2 is normally managed with which product to mamage bleeding

Answer 20

Factor VIII Concentrate

Question 21

Augmentation of factor levels is required for which inherited bleeding conditions

Answer 21

Mild Haemophilia A

Type 2a Von Willebrand’s Disease

Moderate Haemophilia B

Type 3 Von Willebrand’s Disease

Question 22

What does Activated partial thromoboplastin time (APTT) measure

Answer 22

It measures how long it takes your blood to form a clot

Factors VIII, IX, XI,XII and Factors X,V, prothrombin and fibrinogen

Question 23

What does Protrhombin time (PT) measure

Answer 23

how long it takes for a clot to form in a blood sample

Factors VII,X,V prothrombin and fibrinogen

Question 24

The prothrobin time (PT) would be deranged in what

Answer 24

Liver Disease or Warfarin Therapy