A DOCS Education Member writes:
My 45-year-old patient has a history of acid reflux. The man also purges. He isn't especially fearful of dentistry, and we were able to prep and deliver 10 crowns on the upper in two appointments. However, there were difficulties. Three hours into the procedure he began to shake and evince problems emotionally and physically.
I should add that the patient smells of alcohol at every visit, and I have wondered whether he is experiencing withdrawal during procedures. He has body image issues and his solution to stop purging is to not eat anything. He refuses to take in liquids or food, but states that a little bourbon will "set him straight."
The man requires a full-mouth construction so there is much more work to do. I am concerned that should we sedate him and there are subsequent withdrawal symptoms, he will be harmed. Here are my questions:
- Is it safe to work on this patient?
- Will he become so stressed that his blood pressure rises too high?
- How can I comfortably and inoffensively address the possibility of alcoholism?
- Is he a safe candidate for sedation?
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
This man appears to drink significantly by history and his own statements. Alcohol withdrawal so soon after abstention is unlikely—generally this occurs 36 to 48 hours after abstention; however it's certainly probable he would be jittery and tremulous. I'd be more concerned about hypoglycemia. I do not believe sedation is indicated for this patient because he isn't fearful at baseline. In fact, if he's indeed hypoglycemic, sedation would actually be problematic.
Dr. John Hexem, a member of the DOCS Education faculty, responds:
There is a significant chance this patient is indeed going into DTs after about three hours. In his own words, a little bourbon "will set him straight." He is not a candidate for oral sedation or for general anesthesia if he has alcohol on his breath in the morning. He needs straightforward counseling concerning the nature of his situation and also referral to a treatment center.
Language I would suggest: "Sir, I have discussed your situation with my colleagues. We feel that your drinking has left your health in a precarious situation. I cannot proceed with dental care in a manner which is safe for you until you undergo evaluation for alcoholism. Here is a number for a treatment center nearby. I can also recommend Rush in Chicago, Talbott in Atlanta, Hazelden in Minnesota, Health Care Connection in Tampa Bay and Betty Ford in California. I can arrange transportation to an ED right now."
It is also very likely that there are several alcoholism treatment options available in your area.
Document everything that occurs. Having a separate conversation with the wife or a family member can sometimes be helpful. It is entirely appropriate for you to give him the number for local Alcoholics Anonymous groups.
Your concerns are well-founded and on mark.
