15.5
Alcoholism
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 42‐year‐old male presents to you requesting dental implants to help him improve his appearance and find a job. He reports being unable to wear his dentures as his mouth is too sore and dry. He appears emaciated and unkempt.
Medical History
- Alcoholism/alcohol use disorder (AUD)
- Anaemia
- Mixed anxiety‐depressive disorder, under treatment with psychologist
- Insomnia
- History of fall from stairs (2 years ago): right clavicle and humerus fracture, treated with surgery and physiotherapy; residual physical disability (50%)
- Allergy to metamizole
Medications
- Clonazepam
- Diazepam
Dental History
- Last dental visit 2 years ago when the previous dentures were made; no follow‐up visits
- No dental anxiety
- Brushes teeth once a day
- Diet – often forgets to eat; sucks mints to mask the smell of alcohol
Social History
- Divorced, has 4 daughters and 3 sons, but estranged and lives alone
- No regular contact telephone number
- Used to work as a painter but had to stop after the fall, now does occasional ad hoc jobs
- Tobacco consumption: 25–30 cigarettes/day
- Alcohol intake: reports an average of 30 units/week but when he feels lonely admits to binge drinking in excess of 80 units/week
Oral Examination
- Angular cheilitis
- Dry lips/mouth
- Fissured tongue (Figure 15.5.1)
- Partially edentate with multiple missing teeth and lack of posterior occlusal support: #16, #14, #21, #22, #24, #25, #26, #27, #36, #44, #45, #46 and #47 (Figures 15.5.2 and 15.5.3)
Figure 15.5.1 Angular cheilitis, dry lips/mouth, fissured tongue. 
Figure 15.5.2 Partially edentate, xerostomia, gingival recession, poor oral hygiene. 
Figure 15.5.3 Lack of posterior occlusal support on the right side. 
Figure 15.5.4 Full‐mouth periapical radiographs. - Caries: #12, #11, #23, #41, #42 and #43
- Mobility: #15, #12 and #42 (grade I); #11, #31 and #41 (grade II); #17 (grade III)
- Extensive soft and hard deposits and staining all quadrants
- Generalised gingival recession
- Generalised periodontal disease
Radiological Examination
- Full‐mouth long cone periapical radiographs undertaken (Figure 15.5.4)
- Pneumatisation of the maxillary sinus
- Generalised horizontal alveolar bone loss
- #17: severe bone loss (~80%), close proximity to maxillary sinus
- #16: covered retained root
- #12: cervical mesial caries
- #11: cervical caries (mesial to distal); bone loss (~60%)
- #31 and #41: bone loss (~60%)
Structured Learning
- What are the possible contributing factors resulting in xerostomia in this patient?
- Alcohol use (diuretic)
- Anxiety/depression
- Side‐effect of clonazepam/diazepam
- Tobacco use – some evidence that long‐term smoking is associated with reduced salivary flow rates
- Dehydration due to inadequate fluid intake
- What other oral features in this patient may be related to his alcohol use disorder?
- Generalised oral neglect and partially dentate, widespread dental decay and periodontal disease
- Angular cheilitis (anaemia)
- Sore mouth (anaemia)
- Following discussion of the oral findings, the patient agrees to have #17 removed as it is increasingly painful and moves when he tries to eat. What factors do you need to consider in your risk assessment for the management of this patient?
- Social
- Currently unemployed – cost of dental treatment may have an impact
- Capacity/consent impaired by alcohol excess and daily benzodiazepines (diazepam and clonazepam)
- Attendance may be erratic due to alcohol use disorder, depression, insomnia
- Unable to contact the patient by telephone
- Tobacco consumption
- Lack of a suitable escort
- Medical
- Alcohol‐related liver disease may be associated with nausea, weight loss, anorexia, jaundice, confusion, peripheral oedema and increased bleeding (see Chapter 6.1)
- Impaired liver function will also require caution when prescribing drugs (antibiotics/painkillers) which are commonly metabolised in the liver
- Additional alcohol‐related comorbidities may be present (e.g. peptic ulceration)
- Emaciation, lack of regular meals and possible bleeding from a peptic ulcer commonly associated with iron deficiency (anaemia)
- Caution with non‐steroidal anti‐inflammatory drugs due to increased likelihood of peptic ulceration and reported allergy to metamizole
- Dental
- High caries risk: sucks mints daily, poor oral hygiene habits, xerostomia
- High dental treatment needs
- Delayed healing (alcohol excess, malnutrition)
- Related psychiatric conditions, such as depression, will impact on the ability to tolerate dental treatment
- Oral cancer risk – higher due to alcohol excess, tobacco use and malnutrition
- Social
- You advise the patient to avoid alcohol prior to his appointment. How might this impact on his presentation?
- Patients who are trying to stop their drinking can present with withdrawal symptoms including tremors, hallucinations and mood alterations
- This can impact on their ability to consent for and cope with dental treatment
- It may be preferable to schedule an appointment at a time of day when the patient does not usually drink alcohol
- The patient asks you for sedation as he is anxious regarding the dental extraction. What would be your concerns?
- Lack of escort for the appointment and to support the patient at home
- Not recommended as complicated by tolerance to benzodiazepines (patient takes diazepam/lorazepam daily) or, conversely, they may have prolonged duration if there is significant liver damage
- Following extraction of #17, the patient returns asking you again for dental implants. What specific risks would you discuss?
- Cost of dental implant placement (unemployed)
- Difficulty in achieving compliance with stages of implant placement
- Poor quality of bone (osteoporosis linked to heavy drinking) and pneumatisation of maxillary sinuses
- Increased bleeding risk during placement (pancytopenia, liver cirrhosis)
- Infection at the implant site (active periodontal disease in other sites of the mouth, impaired immunity, malnutrition)
- Failure/peri‐implantitis (smoking, self‐neglect, active periodontal disease, suboptimal maintenance, possible bruxism)
General Dental Considerations
Oral Findings
- Neglect may lead to advanced caries and periodontal disease
- This may be exacerbated by underlying anxiety and depression, which can also contribute to attrition, dry mouth and burning mouth syndrome (see Chapters 15.1 and 15.2)
- Excessive alcohol consumption is one of the main risk factors causing violent behaviour – this can result in trauma to the face and teeth
- Alcohol is a risk factor for oral cancer
- Other orofacial features include a smell of alcohol on the breath, telangiectasias, rhinophyma (enlargement of the nose with dilation of follicles and redness and prominent vascularity of the skin, also known as ‘grog blossom’)
- Oral manifestations may also occur as a result of concomitant diseases (Table 15.5.1)
Dental Management
- Dental treatment will be mainly conditioned by behavioral disturbances, severity of liver injury and presence of comorbidities (Table 15.5.2)
Section II: Background Information and Guidelines
Definition
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