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Considerations about the patient with chronic alcoholism admitted in hospital and outpatient services of oral and maxillofacial surgery.

Chronic alcoholism, whether a singular condition or associated with a mental disorder, similar to other drug abuse, represents a great challenge for the staff of oral and maxillofacial surgery during pre-, intra- and post operative period. Undoubtedly, life conditions in our country in the last two or three decades have made only the alcoholism prevalence to be 28-50 % in psychiatric hospitals [1, 2]. It is possible, that some alcoholics abuse or are addicted to other drugs also.

Alcoholism is a disease that occurs when a person becomes addicted to alcohol, experiencing an inner "urge" to use this substance [3]. Alcohol addicts are deeply concerned about its use, and this becomes a daily or weekly priority. Non-alcoholics often do not understand why an alcoholic cannot supress his urge to drink. But alcoholics "crave" for alcohol as common people need food and water, and literally will feel the urge to drink in order to survive. In the absence of alcohol, these patients go through a period of withdrawal (similar to a high-risk drug addict person) with various symptoms: nausea, sweating, tremors, anxiety, insomnia, agitation, aggressiveness.

Oral and maxillofacial implications of chronic alcoholism include:

--poor oral hygiene;

--neglecting dental problems;

--tooth abrasion (through bruxism);

--xerostomia (by atrophy of the salivary glands);

--higher incidence of oral cancer (especially in combination with chronic smoking);

--oral candidiasis (due to poor nutrition);

--delays in wound healing and bleeding tendency (by liver disease);

--oraland maxillofacial trauma (acquired by their aggressive behaviour).

The management of the mentioned problems is made, as appropriate, indental or oral and maxillofacial surgery clinic or in outpatient services, having some peculiarities in approaching chronic alcoholic patients [4], that we will try to present in a synthetical manner.

Before surgical maneuvers, it is often indicated to determine the type of bleeding, because in chronic alcoholic patient there is an increased risk of intra- and postoperative bleeding.

The tendency towards a long term process of healing and the increased risk of postoperative infection may require a greater use of antibiotics in the postoperative period. Perioral injuries and facial bone fractures will be treated by the maxillofacial surgeon, by reference. It should be noted that a significant number of alcoholic patients with trauma in oral and maxillofacial territory have infectious complications (like osteitis, osteomyelitis) after a complicated fracture, because of their attitude of noncompliance to treatment and having a poor oral hygiene.

A careful screening is required at the initial clinical examination in an alcoholic patient, due to his higher risk of oral cancer than in that for a common person. Most carcinomas of the oral mucosa develop in people with chronic ethanol consumption doubled with chronic smoking.

Alcoholic patients have an altered response to many drugs [5]. As they develop tolerance to ethanol, they also develop a tolerance to sedative drugs too (for example) and often need higher doses than usual in order to get the desired degree of sedation.

But all drugs that are metabolized in liver should be administered with caution to a chronic alcoholic. Among the frequently used drugs in maxillofacial surgery, there should be considered: Lidocaine, Mepivacaine, Ampicillin, Aspirin, Acetaminophen, Codeine, Diazepam and the barbiturates.

For patients with long history of chronic alcoholism it was reported the need for a significant increase in the amount of local anesthetic to get the pain control [6].

If a chronic alcoholic uses, abuses or is in addiction on other drugs (often with intravenous administration) he is obviously exposed to a higher risk of getting an infection with hepatitis B virus or human immunodeficiency virus. The major complications of taking drugs are hypotension and cardiac irritability [7]; therefore, the local anesthetics with adrenaline are totally contraindicated for someone who has used (or it is supposed to have used) high risk drugs in the last 48 hours. In such patients, hyperactivity and hypersensitivity reactions to local anesthetics were reported [6].

The management of oral and maxillofacial diseases in a chemically addicted patient, recovered or under recovery (both for alcohol and other drugs) involves additional challenges [8]. In this context, caution should be taken in prescribing drugs with mood alteration potential. These include sedatives drugs (also the analgesia with nitrous oxide/oxygen) and the potentially addictive pain-killers that include almost all analgesic drugs, except the non-steroid anti-inflammatory drugs (NSAIDs)--such as aspirin or ibuprofen. If the prescribing dentist or maxillofacial surgeon has problems in terms of substance used for analgesia in a patient with drug abuse or dependence, he should contact the psychiatrist attending physician. In severe cases of periodontal disease or in oral surgery, the narcotic agents should be prescribed only after the primary agents (ibuprofen) have failed.

Regarding the amount of administered analgesics to an alcoholic, it is recommended to be given for no more than 48 hours and to avoid taking drugs when the pain is only anticipated [9]. Therefore, to reduce the need for postoperative analgesics, we can use a long-lasting local anesthetic (Bupivacaine).

The alcoholics which are in recovery programs (through disulfiram-Antabuse therapy) should avoid any alcohol-based product (for oral or topical use), such as some mouthwash [10]. Fortunately, there are numerous many non-alcoholic mouthwashes.

Chronic alcoholic patients, who experience ethanol withdrawal episodes, may create some trouble in hospital services of maxillofacial surgery, especially in the postoperative period [11]. The withdrawal symptoms (psychomotor agitation, anxiety, hand tremors, insomnia, nausea and vomiting, transient visual, tactile or auditory hallucinations) are the result of central nervous system excitation by sudden removing the depressing agent--in this case, the alcohol [12]. In an attempt to adapt the body to the alcohol content of the cells, the changes occur at the level of neurotransmitter receptors, and therefore, the neurochemical cell activity changes [13]. As a result, the alcohol-dependent patients often require more sedation during anesthesia and more medication to control the pain in the postoperative stage [14]. Therefore, the premedication with longer-acting benzodiazepines in alcohol-dependent patients is recommended to prevent the perioperative and postoperative ethanol withdrawal. But often it is difficult to determine if patient's anxiety, irritability, psychomotor agitation, tachycardia are related to the withdrawal ethanol or to the uncontrolled postoperative pain. The treatment of choice for withdrawal is with benzodiazepines [15]. The most common benzodiazepines used are lorazepam (Ativan) and diazepam (Valium), because they are effective in controlling symptoms and their absorption rates are higher. In cases of liver disease, diazepam is not recommended because of its long-term action. The dietary supplements of B complex vitamins, especially the thiamine, may also be administered to prevent the complications that can occur in patients with ethanol abuse, because the megaloblastic anemia is almost a "rule" in chronic alcoholics.

CONCLUSIONS

Chronic alcoholism is one of the most important public health problems, as cumulative toxic effects of chronic alcohol consumption generates numerous medical and psychiatric problems.

Alcohol dependence, combined or not with other chemical dependencies, leads to a biological and behavior profile that may jeopardize the therapeutic strategy for diseases in the oral and maxillofacial territory.

The early identification of the ethanol withdrawal and the decision for the appropriate therapy are also necessary during postoperative care of the chronic alcoholics.

ACKNOWLEDGMENTS AND DISCLOSURE

The authors declare that they have no potential conflicts of interest to disclose.

REFERENCES

[1.] Agenda Nationals Antidrog: Prevalent consumului de droguri in Romania. Bucuresti, 2005, p. 23-46.

[2.] Cornutiu, G., Patologia alcoolica psihiatrica, Ed. "Mihai Eminescu", Oradea, 1994, pp. 43-93.

[3.] Vrasti, R., Alcoolismul. Detectie, diagnostic si evaluare. Un compendium de scale, chestionare si interviuri, Editura Timpolis, Timisoara, 2001.

[4.] Friedlander, A. H., Mills, M. J., Gorelick, D. A., Alcoholism and dental management. Oral Surg Oral Med Oral Pathol 1987;63(1):42-46.

[5.] Mariani, J. J., Levin, F. R., Pharmacotherapy for alcohol-related disorders. What clinicians should know. Harvard Review of Psychiatry 2004;12(6):351-366.

[6.] Moore, P. A., Adverse drug reactions in dental practice: Interactions associated with local anesthetics, sedatives, and anxiolytics. J Am Dent Assoc 1999;130(4):541-4.

[7.] Ratcliff, J. S., Collins, G. B. Dental management of the recovered chemically dependent patient. J Amer Dent Assoc 1987;114(5):601-603.

[8.] Maxson, P. M., Schultz, K. L., Probable alcohol abuse or dependence: A risk factor for intensive care readmission. Mayo Clinic Proceedings 1999;74:448-453.

[9.] Miers, D. R., Smith, D.P., Chemical dependency. Guidelines for the treatment of recovering chemically dependent dental patients. J Amer Coll Dent 1989;56(1):4, 6-8.

[10.] Allen, K. M., Nursing care of the addicted client, New York, NY: Lippincott Wiliams & Wilkins, 1996.

[11.] Graham, A. W., Schultz, T. K., Mayo-Smith, M. F., Principles of Addiction Medicine. 3rd edition, Philadelphia, PA: Lippincott Williams and Willkins, 2007.

[12.] Sullivan, J. T., Schneiderman, J., Naranjo, C. A., Assessment of alcohol withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale. British Journal of Addiction 1989;84:108-109, 1353-1357.

[13.] Roberts, A., Koob, G., The neurobiology of addiction. Alcohol Health and Research World 1997;21(2):101-106.

[14.] Schick, L., The elderly patient. In: DeFazio-Quinn D.M., Schick L. (Eds): PeriAnesthesia Nursing Care Curriculum: Preoperative, Phase I and Phase II PACU Nursing, St. Louis, Mo: Saunders, 2004, pp. 209-225.

[15.] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.: Washington, D. C., 2000, p. 201.

Correspondence:

Daniela TRANDAFIR "St. Spiridon" Emergency County Hospital of Iasi No. 1 Independence Boulevard, zip code 700111, Iasi, Romania Department of Oral and Maxillofacial Surgery

E-mail: trandafir.daniela@gmail.com

Submission: June, 15th, 2015

Admittance: August, 07th, 2015

Daniela TRANDAFIR--M. D., Ph. D., Assistant Professor, Faculty of Dental Medicine, Department of Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi; Senior Oro-Maxillo-Facial Surgeon, "St. Spiridon" Emergency Hospital, Iasi, Romania

Otilia BOISTEANU--M. D., Ph. D., Lecturer, Faculty of Dental Medicine, Department of Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi; Senior Anesthesiologist, "St. Spiridon" Emergency Hospital, Iasi, Romania

Violeta TRANDAFIR--M. D., Ph. D., Assistant Professor, Faculty of Dental Medicine, Department of Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi; Senior Oro-Maxillo-Facial Surgeon, "St. Spiridon" Emergency Hospital, Iasi, Romania
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Author:Trandafir, Daniela; Boisteanu, Otilia; Trandafir, Violeta
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Sep 1, 2015
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