Alcohol & Drug Misuse

Question 1

Why is consent a problem for alcohol abusers

Answer 1

• These patients may have fluctuating capacity
• Capacity is unlikely when a patient is under the influence
• If a patient has alcohol related brain damage then they may have memory deficit which may impact their capacity
• Better to book for morning appointments as more likely to have capacity

Question 2

Why is LA a problem for patients with alcohol misuse

Answer 2

• Care with local anaesthetic as this is metabolized in the liver, want to keep doses to a minimum
• Lidocaine is fully metabolized in the liver whereas articaine is only 5-10% metabolized in the liver
• Avoid IDB, opt for articaine infiltration instead

Question 3

What analgesia is preferred for alcohol misuse

Answer 3

Paracetamol preferred, adjust dose if required

Question 4

How should anxiety be managed for patients with alcohol misuse

Answer 4

• Inhalation sedation is the safest type in these patients
• IV sedation should be avoided in these patients, even if px previous user, better to refer to anaesthetist led services
• IV sedation/GA can lead to relapse

Question 5

What is disulfaram and what is its relevance to dentistry

Answer 5

• Many recovering alcoholics use disulfiram, it can produce a psychotic reaction when given with metronidazole therefore this AB should be avoided in these patients
• Also inhibits metabolism of benzodiazepines and leads to increased sedative effects if used together

Question 6

What are the oral manifestations of alcohol misuse

Answer 6

• Advanced caries, periodontal disease and NCTSL
• Increased risk of leukoplakia and oral cancer
• Glossitis
• Angular stomatitis
• RAS
• Sialosis
• Rhinophyma
• Erosion
• Nocturnal bruxism
• Dry mouth

Question 7

How should you treat patients who suffer from alcohol misuse

Answer 7

Where you are concerned about prolonged bleeding, liaise with GMP for FBC, coagulation screen & LFTs to determine bleeding risk

Question 8

What are signs of substance misuse

Answer 8

• Loss of reliability
• Mood and behaviour changes
• Impaired ability to drive
• Subjective symptoms with no objective evidence
• Requesting specific drugs
• Progressive deterioration in personal appearance and hygiene
• Tremors
• Constricted or dilated pupils
• Puncture marks, scars or pigmentation over veins

Question 9

What are the medical implications of drug misuse

Answer 9

Neglect of general health
Increased rates of infection - STIs, TB, BBV
Infective endocarditis
Venous thromboses

Question 10

How does substance misuse effect LA

Answer 10

• Substance dependant patients often have low pain thresholds
• Patients who are opioid users (heroin is an opioid) may have resistance to LA
• Patients using cannabis and are given LA with adrenaline can result in prolonged acute tachycardia
• For cocaine users, delay treatment 24h after taking cocaine as has an interaction with LA
• Avoid adrenaline containing LA for px on cocaine, ecstacy and methamphetamines for risk of systemic increase in blood pressure

Question 11

What are problems with anxiety management in patients with substance misuse

Answer 11

• Same as alcoholism
• Venous access may be difficult due to collapsed veins if IV user
• May have tolerance to sedative drugs

Question 12

What is the periodontal risk for px with substance misuse

Answer 12

More at risk of NUG

Question 13

What are the problems with anaesthesia in px with substance misuse

Answer 13

Analgesia may be ineffective
Never prescribe opiates for px (dihydrocodeine)

Question 14

What is the advice for methadone users

Answer 14

• Use a straw
• Drink water after consumption
• Don’t brush teeth immediately after
• Engage with dental services
• Prevention
• Avoid prescribing sugar free as has more street value as can be injected IV