FACT SHEET: Liver Disease (also known as “hepatic disease”)
Note: Viral hepatitis is further addressed in fact sheets titled “Hepatitis A”, “Hepatitis B”, and “Hepatitis C.” Liver transplantation is further addressed in the fact sheet titled “Organ Transplantation.” Alcohol and drug dependencies are further addressed in the fact sheet titled “Substance Use Disorder”.
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- Yes, if the patient/client has active viral hepatitis (acute, chronic, or relapsing) or is otherwise potentially infectious.
- Possibly, if the patient/client has undergone liver transplantation (e.g., during the immediate post-transplantation phase, in which only emergency oral care is indicated).
Is medical consult advised?
- Yes, if the patient/client has history or systemic manifestations suggestive of active viral hepatitis (acute, chronic, or relapsing) or previously undiagnosed chronic carrier state.
- Yes, if patient/client is not receiving ongoing medical care/monitoring for recently acquired hepatitis A or E.
- Yes, if patient/client is not receiving ongoing medical care for chronic carrier state of viral hepatitis (for hepatitis B or C).
- Yes, if patient/client has significant morbidity, including prolonged bleeding time or other manifestations of severe or end‑stage liver disease.
- Yes, if the patient/client has pending, or has already undergone, liver transplantation.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Yes, if the patient/client has active viral hepatitis (acute, chronic, or relapsing) or is otherwise potentially infectious.
- Yes, if there is prolonged bleeding time (e.g., resulting from viral hepatitis or related to severe or end-stage liver disease from any cause).
- Yes, if the patient/client has undergone liver transplantation, because immunosuppressive medication may affect appropriateness or safety.
- Yes, if the patient/client is significantly immunosuppressed from any cause (e.g., from corticosteroids or other immunosuppressive drugs used in the treatment of autoimmune liver disease).
- Yes, if drug or alcohol dependency is of a type or extent that may affect appropriateness or safety of invasive procedures.
Is medical consult advised?
- See above.
Is medical clearance required?
- Yes, if active viral hepatitis (acute, chronic, or relapsing) and/or prolonged bleeding time and/or severe liver disease is suspected on the basis of history and/or examination.
- Possibly, in the case of hepatitis B or C, if the patient/client is being treated with antiviral medications associated with immunosuppression +/- increased risk of infection +/- prolonged hemostasis. Patients/clients on antiviral therapy should be assessed by their physician prior to invasive dental procedures to ensure safety.
- Yes, if the patient/client has untreated alcoholic liver disease. Elective, outpatient dental/dental hygiene care should be deferred pending assessment by a physician regarding bleeding risk, etc.
- Possibly, in severe or end-stage liver disease, if the patient/client’s medical status (e.g., hepatic encephalopathy) could pose a safety risk to the patient/client or the dental hygienist.
- Yes, for the patient/client who has undergone liver transplantation. Bloodwork should be conducted prior to dental hygiene treatment to determine if the patient/client’s platelet count, clotting factors, and absolute neutrophil count are sufficient to prevent hemorrhage and infection.
Is antibiotic prophylaxis required?
- Possibly, if the patient/client has undergone liver transplantation (especially during the immediate post-transplant period). Medical/dental input should be sought for evaluation of medically-induced immunosuppression and infection risks.1
- No, for most patients/clients with liver disease. However, patients/clients with severe liver disease may be more susceptible to dental infection (as a result of disease- or medication-related immunosuppression), and antibiotic prophylaxis may be a consideration.
Is postponing treatment advised?
- Yes, if the patient/client has active viral hepatitis (acute, chronic, or relapsing) or is otherwise potentially infectious; is not receiving ongoing medical care/monitoring for chronic viral hepatitis carrier state or severe liver disease (of any cause, including alcoholic liver disease); or is suspected to have prolonged bleeding time2. See “medical consult” above.
- Possibly, if the patient/client has undergone liver transplantation (depends on timing of invasive procedures relative to transplant procedure and degree of patient/client’s immunosuppression). Refer also to “Organ Transplantation” fact sheet.
- Yes, if the patient/client is medically unstable.
Oral management implications
- Patients/clients with liver disease can pose a significant challenge for the dental hygienist, because the liver plays a vital role in various metabolic and biochemical functions.3 In particular, bleeding tendencies and impaired drug metabolism may need to be addressed in the dental/dental hygiene treatment plan.
- Liver dysfunction is common in patients/clients who abuse alcohol or parenteral drugs.
- Dental surgery is contraindicated in patients/clients with acute hepatitis, acute liver failure, or alcoholic hepatitis.
- Acetaminophen (which can cause hepatotoxicity) should be avoided in patients/clients with severe liver disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution, if at all, due to the risk of gastrointestinal bleeding and gastritis associated with severe liver disease. Aspirin and NSAIDs are contraindicated in patients/clients with altered hemostasis.
- Based on laboratory test findings that demonstrate bleeding tendency, local hemostatic agents and antifibrinolytic agents (e.g., tranexamic acid) may be indicated for invasive dental/dental hygiene procedures.
- In patients/clients with advanced liver disease, drugs metabolized mainly in the liver (such as local anaesthetics including lidocaine) may need to have their dose reduced. Certain antimicrobials (such as erythromycin, metronidazole, and tetracycline) should be avoided entirely. However, most antibiotics prescribed for oral and maxillofacial infections (including beta-lactams, such as penicillin derivatives and cephalosporins) can be safely used in patients/clients with chronic liver disease.
- Some general anaesthetics (e.g., halothane and thiopentone) are generally contraindicated in patients/clients with severe liver disease. Nitrous oxide and isoflurane are usually preferred.
- The efficacy and safety of many drugs are influenced by concomitant alcohol consumption.
- Pre- and post-transplantation considerations are described in the “Organ Transplantation” fact sheet.
- Ecchymoses, petechiae, hematomas, gingival bleeding, jaundiced (yellowish) mucosal tissues, glossitis (especially in alcoholic liver disease), lichen planus, and impaired healing may be signs of liver disease. Candidiasis, angular cheilitis, and chronic periodontal disease are common findings in patients/clients with advanced liver disease. Crusted perioral rash and bruxism may also be manifestations.
- Endogenous staining of the teeth can result from neonatal liver disease.4 In biliary atresia, a green discolouration of the primary dentition may occur. In neonatal hepatitis5, the primary teeth may take on a yellowish-brown colour.
- Gingival fibromatosis is a component of several rare genetic syndromes that have liver manifestations (e.g., Laband syndrome in which there is hepatosplenomegaly). Gingival tissue enlargement usually begins early in life, and within a few years the teeth are nearly or completely covered with firm tissue with a granular, corrugated surface. The enlarged gingivae are typically pale in appearance, and the gingival enlargement leads to protrusion of the lips.
- Tremors of the tongue can occur during alcohol withdrawal.
- Poor oral hygiene and neglect (as manifested by caries) are common manifestations of chronic alcoholism. Other stigmata include angular cheilitis, glossitis, and loss of tongue papillae, which result from nutritional deficiencies. In addition, spontaneous gingival bleeding and mucosal ecchymoses and petechiae can result from vitamin K deficiency, impaired hemostasis, portal hypertension and splenomegaly (causing thrombocytopenia).
- Sialadenosis6 is a common finding in patients/clients with cirrhosis7 of the liver resulting from alcoholism.
- Foetor hepaticus ― a musty, sweet odour to the breath ― is associated with late stage liver disease and liver failure.
- For patients/clients who have undergone liver transplantation, the following conditions may manifest as a result of immunosuppressive medications used to reduce organ rejection: xerostomia, mouth ulcers, candidiasis, and gingival overgrowth (especially with cyclosporine). Oral complications arising in patients/clients with liver transplants are further described in the “Organ Transplantation” fact sheet.
Related signs and symptoms
- Liver disease is a general term for both primary liver ailments and the hepatic sequalae of many diseases and conditions that impair liver function. These include alcoholism8; infections by viruses (e.g., hepatitis A, hepatitis B, hepatitis C, and other hepatitis viruses; Epstein-Barr virus; etc.); autoimmune or related disorders (e.g., Sjögren syndrome, primary biliary sclerosis [PBC], and primary sclerosing cholangitis [PSC]); sarcoidosis; blockages of the flow of bile (e.g., biliary atresia); genetic conditions (e.g., alpha-1 antitrypsin deficiency, hemochromatosis, Wilson disease, tyrosinemia, and glycogen storage disease); malnutrition; reaction to toxins; medication overdose (e.g., acetaminophen); non-alcoholic fatty liver disease (NAFLD); cirrhosis; hepatocellular carcinoma; and metastases (from other primary cancer sites) to the liver.
- Liver disease may be acute (characterized by rapid resolution and complete restitution of organ function and structure once the underlying cause has been eliminated) or chronic (characterized by persistent liver damage, often with progressively impaired organ function secondary to progressive liver cell damage). Liver dysfunction alters the metabolism of proteins, lipids, carbohydrates, hormones, bilirubin, and drugs.
- Non-alcoholic fatty liver disease9 is the most common liver disease in Canada. It affects more than 7 million persons.
- Biliary atresia is the foremost cause of liver failure in children.
- Acetaminophen overdose is the most common cause of acute liver failure.
- Signs/symptoms that strongly suggest liver disease include jaundice (including icterus of the sclera), dark urine, and ascites10. Other stigmata that may indicate liver disease are: abdominal pain; swelling of the legs and feet; easy bruising; fatigue; itchy skin; decreased appetite; intestinal bleeding; decreased libido; cognitive issues (including memory loss); malnutrition; spider angiomas (from dilated blood vessels in the skin); weakness; and weight loss.
- In advanced primary biliary cholangitis, bone pain or spontaneous fracture can occur due to osteoporosis.
- The liver is often enlarged in alcoholic fatty liver disease.
- Tremors of the hands and eyelids may be signs of alcohol withdrawal.
- Extraoral facial signs of alcohol abuse include:
- red facial skin and spider angiomas on the nose;
- yellow facial skin from jaundice caused by liver disease;
- red or swollen eyes; and
- angular cheilitis caused by vitamin B deficiency.
- Nausea, vomiting, abdominal pain, and hypotension result if alcohol is ingested while a person is being treated with an alcohol sensitizing agent.
- In addition to liver damage, long-term alcohol abuse can cause kidney, heart, pancreas, brain, and reproductive system damage, in addition to affecting motor coordination. Malnutrition associated with alcoholism can lead to anemia due to dietary deficiencies in vitamin B12 and folic acid. Alcoholic liver disease can lead to bleeding tendencies, unpredictable metabolism of certain drugs, and risk for spread of infection. Alcoholic cirrhosis may be accompanied by ascites, ankle edema, jaundice, and hemorrhage from esophageal varices.
- Hepatomegaly (enlargement of the liver) occurs in acute leukemia (along with splenomegaly) when leukemic cells infiltrate the liver.
- Osteoporosis and, less commonly, osteomalacia11 can result from chronic liver disease.
- Liver failure is a life-threatening condition that arises in the advanced stages of loss of liver function (e.g., from end-stage cirrhosis or acute reaction to toxins or medication overdose). Early signs/symptoms are non-specific, including diarrhea, fatigue, decreased appetite, and nausea.12 The advanced clinical picture includes hepatic encephalopathy, which leads to confusion, disorientation, extreme sleepiness, coma, and death.
- Signs/symptoms and other issues associated with liver transplantation are described in the “Organ Transplantation” fact sheet.
References and sources of more detailed information
- College of Dental Hygienists of Ontario
- Åberg F, Helenius-Hietala J. Oral Health and Liver Disease: Bidirectional Associations-A Narrative Review. Dent J (Basel). 2022 Jan 21;10(2):16. doi: 10.3390/dj10020016. PMID: 35200242; PMCID: PMC8870998. https://pubmed.ncbi.nlm.nih.gov/35200242/
- Albuquerque-Souza E, Sahingur SE. Periodontitis, chronic liver diseases, and the emerging oral-gut-liver axis. Periodontogy 2020. 2022;89(1):125-141. https://onlinelibrary.wiley.com/doi/full/10.1111/prd.12427t
- Han P, Sun D, and Yang J. Interaction between periodontitis and liver diseases. Biomed Rep. 2016;5(3):267–276.
- Olczak-Kowalczyk D, Kowalczyk W, Krasuska-Slawinska E, et al. Oral health and liver function in children and adolescents with cirrhosis of the liver. Prz Gastroenterol. 2014;9(1):24–31.
- Mitchell O, Feldman DM, Diakow M, Sigal SH. The pathophysiology of thrombocytopenia in chronic liver disease. Hepat Med. 2016;8:39-50. Published 2016 Apr 15. doi:10.2147/HMER.S74612
- Cruz-Pamplona M, Margaix-Muñoz M, Sarrión-Pérez MG. Dental considerations in patients with liver disease. J Clin Exp Dent. 2011;3(2):e127-34.
- Collier J. Bone disorders in chronic liver disease. Hepatology 2007;46(4):1271-1278.
- Suvarna R, Rao PK, Kini R, et al. Oral Manifestations in Chronic Liver Failure. Austin J Dent 2017;4(2):1066.
- Canadian Liver Foundation
- Centers for Disease Control and Prevention
- Ibsen OAC and Peters SM. Oral Pathology For The Dental Hygienist (8th edition). St. Louis: Elsevier; 2023.
- Regezi JA, Sciubba JJ, and Jordan RCK. Oral Pathology: Clinical Pathologic Correlations (7th edition). St. Louis: Elsevier; 2017.
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
- Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.
- Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3rd edition). Baltimore: Wolters Kluwer Health; 2015.
2 If the patient/client is at risk for excessive bleeding, coagulation and hemostasis tests should be sought prior to dental/dental hygiene treatment. In the event of abnormal test values, consultation with a hepatologist or hematologist should occur, with postponement of elective treatment. Emergency treatments should be provided in a hospital setting.
3 Metabolic functions include conversion of sugar to glycogen, secretion of bile for fat absorption, and excretion of bilirubin. Biochemical functions include synthesis of coagulation factors and breakdown of drugs.
4 The staining results from deposition or incorporation of bilirubin in the developing enamel and dentin.
5 Neonatal hepatitis is also referred to as neonatal cholestasis.
6 Sialadenosis is bilateral, painless hypertrophy of the parotid glands.
7 Cirrhosis is an irreversible condition characterized by progressive fibrosis and abnormal regeneration of liver architecture in response to chronic hepatic injury or insult (e.g., prolonged, heavy use of ethanol).
8 Alcohol abuse or dependency can cause alcoholic hepatitis (inflammation of the liver), fatty liver, cirrhosis, and liver cancer.
9 NAFLD results from the accumulation of fat (mainly triglycerides) in the liver in the absence of excessive alcohol consumption. Liver damage ranges from simple steatosis (fat accumulation) to steatohepatitis (fat accumulation with inflammation) to advanced fibrosis to cirrhosis. NAFLD is associated with obesity, diabetes, insulin resistance, and hyperlipidemia.
10 Ascites is abnormal accumulation of fluid in the abdominal (i.e., peritoneal) cavity.
11 Osteomalacia is softening of the bones, usually secondary to severe vitamin D deficiency.
12 Biochemical markers of liver dysfunction include low blood urea; elevated serum liver enzymes (alanine aminotransferase [ALT], alkaline phosphatase [ALP], and aspartate aminotransferase [AST]); elevated serum bilirubin; and decreased serum albumin and total protein.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.