A toothache has been described as one of the most severe forms of acute pain that has been ranked as 8.5/10 [30]. It results when bacteria cause irreversible inflammation of the neurovascular bundle within the dental pulp and root canals (acute pulpitis). Analgesia for acute dental pain may require an opioid or opioid-acetaminophen combination, but definitive treatment entails either an endodontic (root canal) procedure or extraction of the tooth. Postoperative pain can usually be managed with acetaminophen in conjunction with a nonsteroidal anti-inflammatory drug, preferably ibuprofen [31, 32]. For the patient with cirrhosis, however, these analgesics can have adverse effects since most are metabolized in the liver and excreted by the kidneys [33]. Opioids may also be contraindicated due to the risk for developing or exacerbating concurrent encephalopathy and constipation [33]. In addition, concerns with the use of nonsteroidal anti-inflammatory drugs include impaired renal function and gastrointestinal bleeding [33]. Consequently, acetaminophen that does not exceed 3–4 grams per day may be the drug of choice [33] but may not provide adequate relief of pain if it cannot be augmented with other analgesics.

The need for analgesics following dental surgery can, however, be minimized by use of a long-acting local anesthetic such as 0.5% bupivacaine HCl.(Marcaine™) This anesthetic has been available since 1963 and was approved for dental procedures in 1984 [34]. Bupivacaine, in combination with 1:200,000 epinephrine can provide anesthesia, followed by analgesia for seven or more hours [35]. A single dental cartridge of 1.8 ml contains 9.0 mg. of the anesthetic, and, as a guideline, the maximum safe dose for a healthy adult is 10 cartridges or 90.0 mg. per procedure [35]. Bupivacaine is primarily metabolized in the liver and excreted by the kidneys [35], but with accurate injection techniques, local infiltration with one cartridge can anesthetize several adjacent sites. Furthermore, epinephrine slows absorption of the drug. The injection procedure requires slow administration with frequent, intermittent aspiration. Each quadrant in a mouth with an intact dentition would normally contain eight teeth including the wisdom teeth. In the maxilla, anesthesia would require infiltration of anesthetic for each tooth that could be accomplished with less than the maximum recommended dose. The mandible can be anesthetized with regional blocks that require only two cartridges.

If necessary, surgical sites can be reinjected after several hours. Postoperative pain and swelling can also be limited by the application of ice packs for 20-min on/off intervals on the day of and 1 day following surgery. Similar to the prevention of bleeding, tissue manipulation and trauma should be kept to a minimum. On the day of surgery and 1 day postoperatively, the diet should be limited to liquids or soft foods. Saline and 0.12% chlorhexidine gluconate mouth rinses can be started 1 day after surgery to maintain cleanliness of the extraction sites.

Assessment of the dental health status of patients with cirrhosis should be an integral component of their management, particularly if the disease is a consequence of substance abuse and is progressing to liver failure. It is likely that these patients will require dental extractions but studies of outcomes following surgery are limited. Dental extractions performed prior to liver transplantation found no adverse sequelae other than minor bleeding. Surgery can be undertaken using standard practice procedures. Primary concerns appear to be limited to management of postoperative bleeding and pain. Providing interceptive dental care may be an inconvenience but offers far greater benefits than the risks of an acute dental infection and sepsis.