CHRONIC ALCOHOLISM AND DENTAL PRACTICE
Meena S Ranka*, Satish Ranka**, Rohini Kharat***
*Dental Resident; **Medical Officer; ***Unit Chief and Head, Department of Dentistry, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400 012 India.
Chronic alcoholism is a medico-social problem. It is a challenge in planning correct and structured management. This paper aims to give a concise information of the effect of chronic alcoholism to the dentist. A review of psychiatric and dental literature covering the aetiology, prevalence, complications is presented. Medical and dental aspects, both are described in brief to understand the pathophysiology better, as both are inseparable. It is important for the dental practitioner to be aware of the impact of this condition on patients as he or she may be in an ideal position to spot the alcoholic before a medical consultation is made.
Alcoholics anonymous believe that alcoholism is a physically uncontrollable compulsion coupled with a mental obsession. The only way is to stop drinking completely as “for the alcoholic, one drink is too many and one thousand one not enough” thus once an alcoholic, always an alcoholic.
Most often alcoholism is undetected and untreated.
Alcoholism is defined by American Medical Association as “an illness characterized by significant impairment (a type of drug dependence) that is directly associated with persistent and excessive use of physiological, psychological or social dysfunction”.
MEDICAL EFFECTS OF ALCOHOLISM
There are many reported complications of ingestion of excessive quantities of ethanol including malnutrition, neurological disorders, cirrhosis of the liver, aggravation of pre-existing cardiovascular disease, and drug interaction. These all directly or indirectly affect the dental treatment.
A. Nutritional Effects
The nutritional status of alcoholic patients varies according to dietary intake, as with all patients. Alcoholics are broadly divided into 2 groups.
1. Down and out.
2. Middle class secretive.
The down and out alcoholics have a poor diet with low protein contents, as well as being poor in other ways. This is not the case with the middle class secretive group, who have a near normal intake of protein. A relative protein deficiency can occur even from diets with a normal intake of protein if 50% or more of the daily caloric intake is derived from alcohol. This is due to increased protein degradation.
B. AFFECTS ON LIVER
They are similar to those of starvation.
Alcoholic patients are prone to hypokalaemia, especially in cases of chronic liver disease. In cases where serum K+ is normal, the total body K+ level may be decreased due to poor dietary intake, vomiting and diarrhoea.
In the early stages, there is an increase metabolism of drugs, notably barbiturates, intravenous anaesthetic agents etc. In the later stage, when the liver is significantly affected, the metabolism of many drugs is reduced. Such agents include local anaesthetic, analgesics, sedatives and certain antibiotics. Also the production of protein is reduced. The protein affected include prothrombin, which explains the prolonged bleeding tendency seen in these patients.
C. VITAMIN DEFICIENCIES
They are endemic in the down and out alcoholic but less common in middle class secretive patients who almost have a normal diet.
D. IMMUNE SYSTEM
The alcoholic is more liable to viral and fungal infections. This is due to depression of cell mediated immune system. This depression may result from a direct effect on white cell production in the bone marrow as well as depression of cell function. The humoral response is also reduced. These immunological effects, coupled with decreased clotting function, may explain the increased susceptibility to post operative and post-traumatic infections.
E. GASTRO-INTESTINAL SYSTEM
Alcohol is an irritant to the gastrointestinal tract. In the stomach, it may cause lesions ranging from gastritis to acute ulceration and frank haemorrhage. The lesions that are seen in the oesophagus may be the result of chronic vomiting. These often present as tears in the mucosa at the gastro-oesophageal junction the Mallory - Weiss syndrome. There is a view that there is a subclinical regurgitation which is responsible for dental erosion.
F. CARDIO-VASCULAR EFFECTS
It has been suggested that small amounts of alcohol is beneficial to the cardiovascular system. This is due to alcohol promoting the formation of a high density lipoprotein which acts as a scavenger for cholesterol deposits. High intake has a opposite effect and leads to hypertension and alcoholic cardiomyopathy. It can also lead to arrhythmia. The ‘Holiday Heart Syndrome’ has been described, where atrial fibrillation occurs secondary to the ingestion of large amount of alcohol either during holidays abroad or at festive seasons at home.
G. COAGULATION ABNORMALITIES
In advanced alcoholic liver disease there is reduced prothrombin synthesis. Alcohol has a direct effect on the bone marrow leading to thrombocytopenia.
H. DRUG INTERACTIONS
The food and drug administration in the USA has stated that of the 100 most commonly prescribed drugs, more than 50% have at least one ingredient that have reactions with alcohol. Alcohol is present in a large number of over the counter prescription including mouthwashes, antacids, analgesics, anticonvulsants, antidiarrhoeals and tranquilizers. It is theoretically possible that a small amount of alcohol taken in medication may trigger relapse in a reformed alcoholic and thus extreme care must be taken while prescribing for this group of patients.
(A) EXTRA ORAL
Head Injury : Alcohol is a central nervous system depressant. It leads to incoordination, decreased sensory perception, performance and of a long reaction time. Examination under alcohol intoxication is difficult following head injuries and so is to recognize neurological deficit. Alcohol induced neurological disturbances are usually bilateral as compared to traumatic causes which are unilateral.
Few aspects in management
— Frequent neurological assessment is a must.
— Protection of airways : - Gag and cough reflex may be depressed which may be super added by vomiting/blood thus blocking the airways. Displaced tooth or prosthesis may block airways.
— Alcoholic is more susceptible to check to local/general anaesthetic agent and also sedatives. Central nervous system depressant drugs are contraindicated in intoxicated patients.
Enlarged Parotids : Enlarged parotids have been reported in density way back in 1960’s. Enlarged parotid may preceed liver disease. It is due to faulty infiltration or acinar hypertrophy. Alcohol probably decreases salivary secretion.
B. INTRA ORAL EFFECTS
Chronic alcoholics neglect themselves as they are preoccupied with their addiction and they have very poor dental hygiene.
Dental caries : Alcoholics have a high incidence of decayed missing filled teeth and also more missing teeth as compared to non-alcoholics.[21,22]
Chronic inflammatory Periodontal disease : Alcoholics have an increased rate of chronic, advanced generalized periodontitis with inflamed gingivae, loss of stippling, blunting of the interdental papillae and deep pocketing with associated bone loss.
Tooth wear : Increased level of tooth wear due to attrition is present in psychiatric alcoholics. This is due to stimulation of the brainstem reticulo activatory system leading to masseteric muscle activity causing bruxism during rapid eye moment sleep.Advanced dental erosions affecting the palatal surface of upper incisors, erosion of teeth due to chronic vomiting after regular alcoholism binges have been reported.,
Xerostomia secondary to chronic alcoholism may lead to toothwear erosion due to reduced buffering from a smaller volume of saliva.
Intraoral carcinoma : The risk of developing oral squamous cell carcinoma is 10-15 times more in chronic alcoholics. One of the views suggest that the mucosa may be rendered more susceptible to carcinogens.
PRESCRIPTION AND TREATMENT
• Alcoholics are difficult to manage. They miss their appointments, do not cooperate in treatment aspect and leave the course midway. They usually present for emergency treatment rather than a routine checkup.
When they attend clinic, they have a poor oral hygiene with deposits of plaque and calculi along with a coated tongue. There may be an increased level of dental carries or missing teeth and sometimes opportunistic infections or angular cheilitis.
•Local examination is vital to locate premalignant lesions or frank malignancies.
• First step is to diagnose this condition to plan proper management. It includes proper history, which must be neutral and unbiased. Here CAGE questionnaire is invaluable. General examination should include pulse, blood pressure, as an irregular pulse or a high blood pressure may be silent signs of alcoholism.Complete blood counts, liver function test and clotting profile are important before any dental intervention is planned in these patients.
• A dentist should avoid prescribing drugs which have an adverse reactions with alcohol. If interactions do occur patients are more likely to stop taking medications rather than abandon their addiction.
• Alcoholics are also hypoproteinaemics. This increases plasma concentration of drugs and they may be more susceptible to overdose reactions to local anaesthetics particularly amide group.
• Post extraction infection is another entity where caution is the word. Extraction’s should be carried out with utmost caution, minimum trauma to prevent dry sockets.
• Adequate local anaesthetic is to be used as these patients are susceptible to stress of the painful procedure preferably with a vasoconstrictor to reduce systemic absorption.
• Complex treatment is to be avoided until patient comes to term with his problems. Family finances and patient’s resistance do matter.
• The least but also an important point for the dentist, is to provide, a family care, recognize signs of abuse, manifest in other family members.
ALCOHOLISM IN THE DENTAL PROFESSION
Alcoholic dentists are a problem in themselves. Stress of the job and added financial problems are blamed. Also working single handedly and being isolated may drive a person to this addiction. Dentists should also be aware of possibility of their colleagues becoming alcoholics and try to counsel them or refer them to deaddiction centers.
Due to serious outcomes of alcoholism, it is important that the dentists be aware of the effects both generally and especially orally. General practitioners, who see patients regularly for routine examination, are in an ideal position to diagnose premalignant lesions and malignant conditions. The dentist is also in an ideal position to see the warning signs of changes in behaviour or attitudes to dentistry that may be indicative of an emerging alcohol related problem and help in its primary management.
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