DENTAL CARIES AND PERIODONTAL DISORDERS IN CHRONIC LIVER DISEASE Lt Col AC ANAND VSM *,Lt Col PK PARDAL +, Col VP SACHDEV # ABSTRACT Bacterial infections are frequent complications in patients with chronic liver disease (CLD). A potential source of infection may be dental foci. This study was carried out to assess the association of CLD with dental caries and periodontal disease. Dental caries and periodontal examinations were performed prospectively in patients with CLD (group A) and controls without any liver disease (group B). Similar examination was also carried out in alcoholics without liver disease (group C) as well as in cases with portal hypertension but no liver disease (group D) i.e. patients with Non Cirrhotic Portal Fibrosis and Extrahepatic portal obstruction. A total of 231 subjects (Group A:83, group B: 75, group C:46 and group D:27) were studied. Group A included 32 cases with chronic hepatitis B&C, 26 with alcoholic cirrhosis, 14 with postnecrotic cirrhosis, and 11 with cryptogenic cirrhosis. Measures of oral hygiene (p < 0.01), dental care (p < 0.001), and periodontal parameters were worse and the number of teeth reqniring treatment (p < 0.05) was higher in alcoholics with or without cirrhosis than in healthy subjects and nonalcoholic patients with cirrhosis. Alcoholics had a lower, total number of teeth than patients without alcohol abuse and healthy controls (p < 0.01). The dental caries and periodontal status of patients with nonaleohollc cirrhosis did not differ significantly from group B. The severity and duration of liver disease had no influence on dental caries and periodontal disease. The presence of chronic alcohol abuse rather than cirrhosis or portal hypertension is a major predisposing factor for dental caries and periodontal diseases. In alcoholics, these diseases appear to be caused primarily by bad oral hygiene and poor dental care. MJAFI 2001; 57 : 26-30 KEY WORDS: Alcohol abuse; Chronic liver disease; Dental caries; Periodontal disease.
Introduction
teeth and periodontium.
ental caries and periodontal disease have received little attention in patients with chronic liver diseases (CLD). However, in centres where liver transplantation is an option, dental foci need to be controlled in transplant candidates because of their potential role as source of bacterial infections. Patients with CLD are also susceptible to bacterial infections, which may lead to bacteraemia and eventually to death [1]. Increased susceptibility to infections may be related to compromised function of the immune system in such patients. These immune defects include complement deficiency, impaired Kupffer cell and neutrophil function (decrease in adherence, motility and phagocytotic activity leading to decreased ability to kill bacteria) [2,3]. Periodontal disease and dental caries are also due to bacterial infections [4-7]. Gingival inflammation frequently develops in many immunocornpromised states, such as patients with leukemias or other malignancies or those on cancer chemotherapy [8-11 J. There are a few reports of higher incidence of periodontal disease in patients with cirrhosis, but no details on etiology are reported [I2]. The aim of this prospective study is to assess whether CLD alone can lead to the deterioration of
Materials and Methods.
D
Patients : Four groups of patients were subjected to detailed oral examination between 1995-99 at two tertiary care hospitals of Armed Forces at Pune and Chandirnandir :
* Group A consisted of patients with chronic liver disease which included chronic hepatitis and cirrhosis of liver. The diagnoses were based on histological criteria or, if liver biopsy was not possible because of reduced blood coagulation, on clinical, serological. and laboratory findings [13]. Severity of cirrhosis was classified according to Child criteria [14]. * Group B consisted of patients who attended gastroenterology OPD and were diagnosed to have functional bowel disease and those attending surgical OPDs for orthopaedic complaints involving long bones. All these subjects had no clinical or biochemical evidence of liver disease. Only subjects consuming less than 60 ml of alcohol per day, with normal transaminases and normal blood glucose levels were included. Patients who were considered immunocornprised for any reason (namely those with diabetes mellitus, uraemia, malignancy of any kind, those on steroids or immunosuppressive drugs or my positive individuals) were not included in this group. * Group C consisted of alcohol dependent patients on psychiat-
ric follow up (for deaddiction) who had no evidence of liver dis-
ease.
* Group D consisted of consecutive cases with Portal Hypertension but no liver disease (namely those with Non Cirrhotic Portal Fibrosis and Extrahepatic Portal Obstruction).
'Classified Specialist (Medicine and Gastroenterology), "Classified Specialist (Psychiatry), Command Hospital (Western Command) Chandimandir-134 107 nSenior Adviser (Oral Surgery),Command Military Dental Center. Chandimandir-134 107.
Dental Disorders in Chronic Liver Disease All these patients underwent meticulous dental examination by the same dental team. Each person examined was asked standardized questions regarding alcohol consumption, smoking, dietary habits, dental hygiene and level of education. The dental and periodontal examination included: (a) count of total number of teeth and of the number of carious teeth, including extremely decayed teeth requiring extraction. Twenty-eight teeth were accepted as a functional complement. Third molars were not included.(b) an index of oral hygiene (15) calculated as the plaquefree surface expressed as a percentage of the total surface of all teeth. (c) measurement of the loss of attachment from the cemento-enamel junction to the bottom of the clinical pocket as described by Glavind and Loe [16]. This is an important parameter of periodontal disease because it expresses loss of periodontium. The results are given as mean ± SD or mean (range). Student's t-test, Chi-square-test, and Kruskall Wallis test (Chi Square, approximation), were used for statistical analysis [17]. Differences were considered significant when p < 0.05.
27 No carious teeth were found in 61 of group A, 65 of group B, 24 of group C and 22 of group D subjects (pSOy 41-50 31-40 21-30
Introduction
teeth and periodontium.
ental caries and periodontal disease have received little attention in patients with chronic liver diseases (CLD). However, in centres where liver transplantation is an option, dental foci need to be controlled in transplant candidates because of their potential role as source of bacterial infections. Patients with CLD are also susceptible to bacterial infections, which may lead to bacteraemia and eventually to death [1]. Increased susceptibility to infections may be related to compromised function of the immune system in such patients. These immune defects include complement deficiency, impaired Kupffer cell and neutrophil function (decrease in adherence, motility and phagocytotic activity leading to decreased ability to kill bacteria) [2,3]. Periodontal disease and dental caries are also due to bacterial infections [4-7]. Gingival inflammation frequently develops in many immunocornpromised states, such as patients with leukemias or other malignancies or those on cancer chemotherapy [8-11 J. There are a few reports of higher incidence of periodontal disease in patients with cirrhosis, but no details on etiology are reported [I2]. The aim of this prospective study is to assess whether CLD alone can lead to the deterioration of
Materials and Methods.
D
Patients : Four groups of patients were subjected to detailed oral examination between 1995-99 at two tertiary care hospitals of Armed Forces at Pune and Chandirnandir :
* Group A consisted of patients with chronic liver disease which included chronic hepatitis and cirrhosis of liver. The diagnoses were based on histological criteria or, if liver biopsy was not possible because of reduced blood coagulation, on clinical, serological. and laboratory findings [13]. Severity of cirrhosis was classified according to Child criteria [14]. * Group B consisted of patients who attended gastroenterology OPD and were diagnosed to have functional bowel disease and those attending surgical OPDs for orthopaedic complaints involving long bones. All these subjects had no clinical or biochemical evidence of liver disease. Only subjects consuming less than 60 ml of alcohol per day, with normal transaminases and normal blood glucose levels were included. Patients who were considered immunocornprised for any reason (namely those with diabetes mellitus, uraemia, malignancy of any kind, those on steroids or immunosuppressive drugs or my positive individuals) were not included in this group. * Group C consisted of alcohol dependent patients on psychiat-
ric follow up (for deaddiction) who had no evidence of liver dis-
ease.
* Group D consisted of consecutive cases with Portal Hypertension but no liver disease (namely those with Non Cirrhotic Portal Fibrosis and Extrahepatic Portal Obstruction).
'Classified Specialist (Medicine and Gastroenterology), "Classified Specialist (Psychiatry), Command Hospital (Western Command) Chandimandir-134 107 nSenior Adviser (Oral Surgery),Command Military Dental Center. Chandimandir-134 107.
Dental Disorders in Chronic Liver Disease All these patients underwent meticulous dental examination by the same dental team. Each person examined was asked standardized questions regarding alcohol consumption, smoking, dietary habits, dental hygiene and level of education. The dental and periodontal examination included: (a) count of total number of teeth and of the number of carious teeth, including extremely decayed teeth requiring extraction. Twenty-eight teeth were accepted as a functional complement. Third molars were not included.(b) an index of oral hygiene (15) calculated as the plaquefree surface expressed as a percentage of the total surface of all teeth. (c) measurement of the loss of attachment from the cemento-enamel junction to the bottom of the clinical pocket as described by Glavind and Loe [16]. This is an important parameter of periodontal disease because it expresses loss of periodontium. The results are given as mean ± SD or mean (range). Student's t-test, Chi-square-test, and Kruskall Wallis test (Chi Square, approximation), were used for statistical analysis [17]. Differences were considered significant when p < 0.05.
27 No carious teeth were found in 61 of group A, 65 of group B, 24 of group C and 22 of group D subjects (pSOy 41-50 31-40 21-30
