Chemical Dependency: Alcoholism
Center for Continuing Dental Education
Next to dental disease, alcoholism is probably one of the most frequently encountered diseases encountered by the practicing dental professional. Most patients that are alcoholic will deny or be unaware of the full extent of their problem, however.
Diagnosis is difficult as most alcoholics maintain normal social and employment relationships and present a "normal" appearance. It is imperative, though, to be able to identify patients that have problems with alcohol. Dental professionals, by virtue of the fact that they may be seeing their patients for numerous appointments over extended periods of time and generally develop rapport with them, have the opportunity to detect the oral and general manifestations associated with alcohol abuse and alcoholism.
To begin with, a complete medical history, with an emphasis on alcohol use, organ damage, past medical care and hospitalizations needs to be taken with follow-up questions asked if alcohol problems are suspected. All patients should be asked if they are recovering from alcoholism and any other chemical dependency as part of the medical history interview. Neutral, non-judgmental screenings as described in Section 3 of this online course, such as the CAGE Questionnaire, can be used to determine if an alcohol problem exists. If a problem does indeed exist, we can provide information and direct the patient to the appropriate support groups for counseling and treatment of alcohol abuse.
The dentist and dental hygienist will need to develop appropriate treatment plans to accommodate their alcoholic (or alcohol abusing) patients' needs, taking into account these patients' generally unreliable nature. Many times appointments are not kept, and there is poor compliance with oral hygiene as well as maintenance of their general physical health.
Additionally, an alcoholic is more likely to present at a dental office for emergency treatment rather than for a routine dental exam. There is a strong need to consult with their physician and other health professionals that are involved in their medical care if any questions arise.
To begin, some general principles that should be followed when treating an alcoholic patient are to always examine their oral mucosa for pre-cancerous or cancerous indications, institute frequent recall appointments due to the increased risk of oral cancer, periodontal disease, caries and other soft tissue changes, and provide fluoride treatments and oral hygiene instructions at each appointment.
The oral health of patients with alcohol-related disorders may vary significantly from those patients who are not affected by alcohol.
The list of oral manifestations is lengthy and many of the manifestations can be associated with other systemic diseases, also. Following are extra-oral manifestations associated with these patients:
Other general appearance features include:
The intra-oral manifestations include:
Alcohol can affect the life of certain restorative materials, particularly composites. Research has shown that composites are susceptible to chemical softening from the ethanol present in alcoholic beverages, and this will decrease their wear resistance .
Advise patients that you suspect or know to have alcohol-related disorders to abstain from smoking and drinking alcohol for at least 72 hours after cementation of porcelain veneers with dual-cure resin cements as the alcohol can jeopardize the porcelain-cement-enamel bond. Prior to dental restorative treatment, the dentist needs to ascertain any alcohol abusing patient's condition to determine to what degree they consume alcohol. It may be more effective to provide full coverage for a tooth rather than a large composite in an anterior tooth because of this. Also, an amalgam may be chosen over a composite resin for a conservative posterior lesion. Full gold coverage may also be preferred over large amalgam buildups, especially in those alcoholic patients that brux or are caries-active.
A thorough extra- and intra-oral exam needs to be performed to detect any soft tissue changes with may be indicative of squamous cell carcinoma which is directly related to heavy drinking and tobacco use. Heavy drinkers have a 10% greater chance of developing oral cancer than minimal drinkers.
A leukoplakia, erythroplakia or any other suspicious lesion should be biopsied to ascertain whether a malignancy exists in this high-risk patient. A majority of squamous cell carcinomas, including cancer of the oral cavity, pharynx, tongue and esophagus are directly connected to heavy drinking and the use of tobacco.
The defense system is depressed by alcohol as alcohol interferes with formation and deposition of collagen and can lead to an increase in post-surgical healing time. Alcoholics are also more prone to post-extraction infections, consequently carry out all extractions with as little trauma as possible with precautions to prevent a dry socket from occurring. Some references state that chronic alcoholic patients should be provided with antibiotic therapy following oral surgery procedures.
Candidal infections associated with an impaired immune system are also present. The alcoholic patient is more vulnerable to viral and fungal infections since their immune system is depressed.
The synthesis of plasma proteins is depressed in severe liver disease resulting from alcoholism. Vitamin K is absorbed poorly which leads to decreased synthesis of a number of clotting factors, as well. Consequently, hemorrhage can be difficult to manage - if surgery is planned, consultation with hematologist is necessary. Advanced alcoholic liver disease leads to reduced prothrombin synthesis and can have a direct effect on the bone marrow which can lead to thrombocytopenia.
Liver damage profoundly affects drug metabolism. Alcoholics with "normal livers" have faster than normal drug metabolism, alcoholics with mild liver disease (fatty liver) have normal drug metabolism, and alcoholics with severe liver disease, hepatitis or cirrhosis have slower than normal drug metabolism. How would the clinician know this? They probably wouldn't unless the patient offered this information. That is why consultation with the patient's physician is critical when drugs will be administered.
If alcohol is consumed while the patient is also taking other drugs, potentially lethal results can occur. At least half of the top 100 most-prescribed drugs contain at least one ingredient which is known to interact adversely with alcohol - sometimes after only one drink. Twenty percent of individuals over the age of 65 use some type of medication which can place them at risk for developing a drug-alcohol reaction. Dental professionals need to be aware of how the alcoholic status of their patient will affect the use of local anesthetics, antibiotics, over-the-counter medications, and drugs that may be prescribed to their patients pre- or post-dental treatment. When in doubt, ALWAYS consult your Dental Drug Reference.
Any lipid-soluble drug or a drug that is metabolized in the liver should be administered with caution to the alcoholic patient. Over-the-counter medicines that interact with alcohol include aspirin, anti-histamines and acetaminophen. Aspirin, as well as aspirin-containing drugs and other non-steroidal anti-inflammatory drugs (NSAIDS) can create gastritis when taken concurrently with alcohol and can also exacerbate hemostatic abnormalities. The metabolism of acetaminophen is increased and the possibility exists for this to lead to hepatotoxicity and hepatic injury. Patients should be cautioned to refrain from taking more than 4 grams (or 8 extra-strength tablets) of acetaminophen per day if they have underlying alcohol-related liver disease.
Frequent drug-alcohol interactions occur when minor tranquilizers are prescribed, as well as morphine barbiturates, anticonvulsants, anticoagulants, antihypertensives and antibiotics.
Amides are primarily metabolized in liver; while esters are hydrolyzed by plasma pseudocholinesterase. If the dental clinician doesn't know the magnitude of the patient's liver problem, esters may be the better choice (Benzocaine) as they may lessen the risk of an adverse drug reaction or medical complication. However, studies have shown that the use of lidocaine (an amide), when carried out appropriately, has not been associated with any side effects. Studies have also shown a prolonged effect to local anesthetic agents by alcoholics, and also that long-term heavy drinkers, when sober, are more difficult to anesthetize and have a decreased reaction to barbiturates, sedatives, bonzodiazepines and other similar drugs. The effects are just the opposite when the patient is inebriated, though. Other studies have shown that alcoholics in recovery are not at an increased risk for inadequate pain control with local anesthetic agents.
Systemic complications that affect the patient's cardiovascular system make alcoholic patients susceptible to the stress some experience when undergoing dental treatment. Therefore, it is critical that adequate local anesthesia is used, with vasoconstrictor, to increase the efficacy of the anesthetic and also to diminish its systemic absorption.
Tetracycline and erythromycin are metabolized by the liver and should therefore be used with caution. Penicillins and cephalosporins are excreted in the urine and are unaffected by liver damage that may be present.
The clinician also needs to identify the recovering alcoholic so over-the-counter and prescription medicines are not dispensed which contain alcohol or other drugs which can trigger an episode of drinking, such as chlorohexadine rinses, over-the-counter mouthwashes, antiplaque rinses, and fluoride rinses. Some over-the-counter mouthwashes are over 25% alcohol. Also, avoid prescribing medications that have an adverse reaction with alcohol (always check the Dental Drug Reference which should be in every dental office). If reactions do occur, the patient will probably discontinue the medication rather than abandon their addiction.
If your patient is into recovery and is taking disulfiram as an adjunctive therapeutic measure, even minute amounts of alcohol consumed can result in a violent reaction, ranging from respiratory depression to cardiovascular distress. This can occur from fluoride rinses containing alcohol, chlorhexadine rinses, and other agents that contain even small amounts of alcohol which are used in dentistry. It is imperative that these patients not come in contact with any alcohol-based products OR nitrous oxide. If you must use one of these agents, the patient should discontinue the disulfiram at least 30 days prior to the procedure. The patient's physician should be contacted to coordinate treatment.
When treating the recovering alcoholic, mood-altering drugs are not necessarily contraindicated if the patient is experiencing severe pain or if the scheduled operative procedures require the use of sedation and/or anesthesia. The following protocol should be followed, however, if this situation presents itself:
- Advise the patient and one of their family members of the type of drug that will be used and its potential side effects.
- Consult the patient's physician and/or recovery team to advise them of the treatment plan and the drugs that will be used. They may also make recommendations for pre- and post-care of the patient.
- If a prescription needs to be filled, a family member or their Alcoholics Anonymous sponsor (if one is available) should be the one that provides the drug to your patient when needed.
- Recommend to the patient that s/he intensify their activities with their recovery group to get them through the dental treatment that is requiring the use of mood-altering drugs.
- Obviously, prescribe only the amount of drug that is needed, and do not prescribe refills.
- Provide reassurance to your patient that you will do everything that is needed to get them through their treatment.
Congratulations - you have just completed the second module of this online course.
Return to the Table of Contents to continue and click on Module 3.
