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


  • 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)
    Photo depicts angular cheilitis, dry lips/mouth, fissured tongue (S).
    Figure 15.5.1 Angular cheilitis, dry lips/mouth, fissured tongue.

    Photo depicts partially edentate, xerostomia, gingival recession, poor oral hygiene (S).
    Figure 15.5.2 Partially edentate, xerostomia, gingival recession, poor oral hygiene.

    Photo depicts lack of posterior occlusal support on the right side (S).
    Figure 15.5.3 Lack of posterior occlusal support on the right side.

    Photo depicts full-mouth periapical radiographs (L).
    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

  1. 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
  2. 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)
  3. 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
  4. 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
  5. 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
  6. 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


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Nov 6, 2022 | Posted by in Implantology | Comments Off on Alcoholism

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