Talking about booze

Most if not all dentists will be aware that alcohol is, especially in conjunction with tobacco use, a primary risk factor for oro-pharyngeal cancer, particularly (but not exclusively) in the over 50s.

 

Rather fewer, I suspect, will be aware that misuse of alcohol will affect gingival recession and periodontal attachment loss. By misuse, I mean either binge drinking in young patients, or the more insidious regular consumption above recommended levels often by older – and frequently more affluent – patients.

 

Once alcohol drinking becomes truly risky – towards dependence levels – then clearly more serious concerns arise too. Regular patients become less reliable and miss appointments. Personal care is neglected, including oral care, and the oral condition becomes unstable and deteriorates.

 

At these levels, the dental team may often suspect or be concerned about obvious signs such as reddened face, bloodshot eyes, parotid enlargement or even systemic signs of liver disease.

 

Tragically, alcohol leads to over 1.2m hospital admissions in England each year with a combined social cost of over £21bn, according to Alcohol Concern. As well as deaths from the effect of the disease, thousands of injuries are suffered, and hundreds of fatalities due to drink-driving. Houston, we have a problem!

 

Yet evidence suggests that whilst dentists have the opportunity to screen up to 1m patients a week in the UK, we are reluctant to engage on the topic of alcohol use or misuse.

 

A small survey in Scotland (12 dentists) by Shepherd et al showed that dentists were poorly informed about safe drinking levels, and were uncomfortable about discussing the issue with patients. They cited embarrassment, irrelevance to dental

care, and concern for undermining the patient-dentist relationship as prime reasons for not engaging with this topic.

 

A Denplan survey of 420 dentists conducted in 2012 that whilst 70 per cent claimed to ask about alcohol consumption (with a further 17 per cent asking new patients only), about one in 10 dentists did not think it important to pursue such enquiries and only two thirds thought it was ‘very important’.

 

How to approach such a delicate topic? There is little in the literature to support intervention in the out-patient sphere, however there is general suggestion that brief ‘motivational interviewing’ advice on such matters, when delivered by

members of the dental team, could bring about behaviour change.

 

One suggestion offered by Neff and co-workers and currently under investigation, is the provision of ‘personalised biofeedback’, that is to say, giving patient individual risk assessments. Such procedures are currently being trialled both in

the NHS England Capitation and Quality pilots, and also in Denplan Excel’s DEPPA risk assessments. In these assessments, data on alcohol consumption is routinely collected from patients at intervals. This provides an opportunity to ask the patient:”Do you know what the recommended limits for alcohol consumption are?” Shepherd noted that his dentists were unsure of these: generally two to three units

 

per day for men (up to 21 units per week), and one to two units daily for women (up to 14 units per week). Hepatologists would also add that it is important to have at least two to three days which are alcohol-free each week.

 

One approach is then to comment non-judgmentally on the patient’s individual consumption level. So for the male patient who admits to drinking 2-3 drinks a day, it is reasonable to say: “Did you know that fewer than one in 10 people drink that much?”

 

The emphasis in this approach is not to challenge, much less to counsel or lecture the patient, but to provide information that is relevant to the individual and which may give them a short, simple message which they can consider and think over. The

evidence is that such short messages can be effective without creating a difficult situation in the practice.

 

Of course, if more serious symptoms are detected, it is the ethical responsibility of the dental team to refer the patient to their GP for further investigation and if necessary, signposting to effective treatment. In such cases it is sufficient to note the signs seen and any symptoms reported.

 

At the same time, the dental team needs to be aware of potential contra-indications that exist where the patient is, or is suspected to be, an alcohol misuser. Aspirin and nonsteroidal anti-inflammatory agents should be avoided, to preclude

abdominal bleeding, and excessive or prolonged post-operative bleeding due to depression of coagulant agents may be anticipated.

 

Dry January is a campaign by Alcohol Concern, the UK’s leading charity campaigning for safer alcohol use. New Year is a good time for resolutions, and an opportunity for all to give their metabolism a chance to recover from Christmas excesses. For many, the results can be lifechanging! To sign yourself up to become an ‘Out to Dry’ Champion, head over to the Dry January website at www.dryjanuary.org.uk. You could even encourage your patients to take on the Dry January challenge with you.

 

 

References available on request.