Management Of Alcohil Dependent Pt

Question 1

PT with alcohol misuse have dental issues:

Answer 1

High incidence of dental disease (poor OH-caries, perio; tooth surface loss, oral cancer, trauma/interpersonal violence, halitosis and staining

Other points to consider:
PT management issues
Alcohol related liver disease
Alcohol reduction advice

Question 2

How to identify “at risk” patients

Answer 2

History:
Ask about alcohol intake
Medications ( vitamin supplements such as thiamine/B1 to prevent alcohol brain disease ; diazapam for alcohol withdrawal symptoms)

Examination:
Smell of alcohol on breath( chewing gum /mints to mask it)
Signs and symptoms of alcohol related liver disease (stigmata)

Special Investigations:
Bloods -liver function test
- deranged alkaline phosphatase, ALT, AST can be non-specific indicators of liver damage
-high gamma-glutamyl transferase are more specific of alcoholic liver disease

Bloods- clotting screen
- clotting factors produced in the liver and/or reduced vitamin K absorption
- prolonged prothrombin time(PT) and activated partial thromboplastin time (APTT) and thrombin time (TT) but normal platelet activity

Question 3

Patient management issues

Answer 3

Alcohol misuse associated behaviour - disinhibition, aggression, unpredictability
Poor dietary habits
Poor oral hygiene/neglect
Poor attendance/engagement
High levels of smoking/recreational drug use
Masked pain- delayed presentation

Question 4

Oral cancer in alcohol dependent pt

Answer 4

30% of oral cancer cases is alcohol related

5x increased risk in heavy drinkers (more than 4 drinks a day)

Increased risk of synergistic effects with smoking

Mechanism is unknown- direct effect of alcohol/ethanol on DNA or acting as solvent for other carcinogens (e.g. tobacco products)

Question 5

Liver disease and dentistry

Answer 5

Bleeding risk:
Primary care: assess bleeding risk and if significant, refer to specialist/secondary care services

Drug metabolism:
Lignocaine toxicity
Analgesia- paracetamol, NSAIDs, aspirin
Disulfiram reactions- metronidazole

Question 6

Liver transplants and dentistry

Answer 6

Immunosuppression:
Impaired healing- prevention of dental disease
Drug reactions: cyclosporin-gingival hyperplasia

Graft versus host disease (GvHD)
Extensive lichenoid reactions
Sclerosis/ trismus