(19) Management of Peridontal Disease in Cirrhosis: A Survey of Liver Transplant Centers in the U.S.

Abstract:

Introduction: Periodontal disease is uniquely consequential in patients with cirrhosis as an obstacle to liver transplantation and as a driver of hepatic fibrosis. Effective management of this disease, including dentoalveolar surgery, is essential for patients awaiting liver transplant due to risk of infection on high dose immunosuppression. Sepsis due to dental infection has been reported post-transplant by 9% of transplant centers in the United States (US), while 11% of these centers encounter cases of transplant cancellation due to dental infection. Periodontitis also has been shown to promote chronic liver disease progression as a source of chronic inflammation and recurrent bacteremia. Considering this evidence, treatment of periodontitis may be underemphasized in this population.

Methods: We conducted a survey of high-volume liver transplant programs from each region of the US (Northeast, Southeast, Southwest, Midwest, West) to evaluate their insights regarding the clinical significance of periodontitis and barriers to treatment. Questions regarding the importance of specific interventions were rated on a scale of 1 to 10. Specific obstacles that might limit treatment of periodontitis were assessed as highly significant, moderately significant, or little/no significance.

Results: A total of 11 transplant centers were surveyed with a combined volume of 1,808 liver transplants in 2023. Surveys were conducted during the first quarter of 2024 and included at least two centers per region. (Figure 1) Treatment of periodontitis was consistently rated as extremely important for patients awaiting liver transplantation (average 9.36) and was frequently cited as a requirement for insurance authorization of transplantation. The importance of periodontitis treatment as an intervention to slow disease progression in chronic liver disease was variably rated across centers (average 2.64). Centers conducting research in the study of disease progression in cirrhosis prioritized treatment of periodontal disease. One hundred percent of respondents classified lack of dental insurance or financial concerns as highly significant as an obstacle to treatment. Concern for bleeding complications was reported as a moderately significant obstacle by 82% of centers. (Table 1)

Discussion: Patients with cirrhosis have been shown to have a higher prevalence of periodontal disease. (Figure 2) Sepsis due to dental infection is a risk factor for mortality in post-transplant liver patients, while chronic inflammation related to periodontitis has been shown to promote progression of chronic liver disease. Treatment of active periodontal disease has been shown to significantly reduced liver enzyme levels and endotoxin levels in patients with fatty liver disease in recent randomized, controlled trials. Surgical interventions such as gingival flap, alveolar grafting, alveoplasty, and tooth extraction are often perceived as high-risk in patients with cirrhosis due to associated thrombocytopenia and abnormal coagulation factors. A 2006 report of dentoalveolar surgery in 35 pre-transplant cirrhotics demonstrated a 50% risk of prolonged bleeding in a subset of patients requiring >10 extractions. Rates of postoperative bleeding in patients with cirrhosis have been low in subsequent studies. In 2021, the American Dental Association concluded that the risk of bleeding associated with oral surgery in patients with cirrhosis is low despite decreased platelets and abnormal coagulation lab profile. Treatment of periodontitis and its complications may dramatically impact the clinical course of patients with cirrhosis awaiting liver transplant as well as patients with chronic liver disease. Promoting awareness regarding the relationship between periodontal disease and cirrhosis may benefit the patients we serve. Further research is warranted in the study of periodontal disease in this patient population.Key References Guggenheimer J. A survey of dental care protocols among US organ transplant centers. Clin Transplant. 2005;19:15–18.Akinkugbe AA. Peridontitis and non-alcoholic fatty liver disease. J Clin Periodontol. 2017;44:1077-1087Rech B. Risk of bleeding during oral surgery in patients with liver cirrhosis. J Am Dent Assoc 2021;152(1):46-54.e2.

Table 1: Liver transplant center survey results compiled by U.S. region.
Figure 1: Liver Transplant Centers Surveyed: Cedars-Sinai, Northwell Health, Johns Hopkins, University of North Carolina – Chapel Hill, Ochsner Health System, Cleveland Clinic, University of Chicago, Houston Methodist Hospital, Mayo Clinic – Arizona, University of California Los Angeles (UCLA), University of California San Francisco (UCSF)
Figure 2: Periodontitis in a Cirrhotic