Abstract
Purpose The purpose of this narrative review of the literature was to examine the current evidence on alcoholism and the consequences on oral and general health, in addition to implications to enhance dental hygiene practice for individuals with alcohol use disorder (AUD).
Methods The search was developed for Medline (via Ovid) and then translated to Cinahl, Scopus, and Web of Science Core Collection. Search results were limited to 2016-present, humans, and English language. Results were exported to EndNote 21 (Clarivate Analytics) for deduplication and uploaded to Rayyan for screening. Two reviewers independently screened titles and abstracts against the inclusion criteria and conflicts were discussed until consensus. A second set of reviewers independently screened titles and abstracts, conflicts were discussed until consensus.
Results Of the 406 articles, 383 were excluded. A total of 23 articles were included and categorized into five domains: general health (n=6), screening tools and education (n=5), oral health (n=4), periodontal diseases and conditions (n=4), and cancer (n=4). General health conditions identified included: cardiovascular events, ischemic stroke, hemorrhagic stroke, liver cirrhosis, pancreatitis, injuries sustained from traffic accidents, and secondary cancers. Microbial dysbiosis was identified in the gut microbiome, respiratory tract and oral/gut. Oral conditions included: AUD risk of poor oral hygiene, bruxism symptoms/tooth wear, necrotizing periodontal diseases and peri-implant disease. The AUDIT-C was found to be a reliable screening tool to identify patients at risk of hazardous alcohol consumption in the dental setting.
Conclusion Excessive alcohol consumption increases morbidity and mortality risk due to the association of chronic health conditions, inflammation and secondary cancers.
INTRODUCTION
Alcohol use disorder (AUD) impairs one’s ability to control their alcohol consumption despite its negative impact on their life.1 About 29.5 million individuals experienced AUD in 2022, or 10.5% of the United States (US) population over the age of 12 according to the National Survey on Drug Use and Health.2 AUD affects people of all genders, races, and ethnicities.2 Statistically, adults aged 18-25 are at the highest frequency to develop symptoms of AUD.2
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-V) lists 11 symptoms indicative of AUD.1 Formal diagnosis of AUD is appropriate when at least 2 symptoms are present within a 12-month period as assessed by a behavioral health specialist.1 Diagnostic symptoms include the inability to think of anything but a drink, inability to control the amount of alcohol consumed, failure to limit or stop drinking, increased tolerance of alcohol, and the onset of withdrawal symptoms when the effects of alcohol wear off.1 Diagnostic symptoms of AUD additionally include consuming alcohol despite its impact to one’s personal life, continuing to drink alcohol despite worsened mental health or blackouts, or participating in dangerous situations while drinking.1 The presence of 1-2 symptoms within 12 months indicates mild AUD, 4-5 symptoms indicates moderate AUD, and 6 or more symptoms indicates severe AUD.1
When an individual consumes excess alcohol, the liver cannot completely remove toxins before alcohol enters the bloodstream.3 As a result, chronic alcohol abuse may lead to organ dysfunction, cell damage, and widespread inflammation.3,4 In fact, the World Health Organization (WHO) reports alcohol as the cause of over 200 diseases, conditions, and injuries, including mental and behavioral disorders.5 Notably, AUD has been directly linked to cancer, liver disease, pancreatic disease, and cardiovascular disease.3–6 Alcohol abuse also directly affects one’s oral health, including increased tooth stain, halitosis, mucosal damage, altered salivary composition.7,8 Those with AUD are also at a higher risk of periodontal disease and dental caries.9
The American Dental Hygienists’ Association (ADHA) Standards of Clinical Practice includes alcohol use as a factor to be incorporated into risk assessments as part of routine, patient-centered dental hygiene care.10 These standards also emphasize the application of suitable risk assessment tools.10 Based on the ADHA Standards of Clinical Practice, this information about lifestyle habits and oral status must be combined with patient priorities to develop the most accurate and appropriate prevention and treatment plan to promote total health.10 Currently, there is a lack of narrative reviews on oral and general health implications of alcoholism for dental hygiene practice. The rising prevalence of alcohol use among populations and the limited available evidence warranted this investigation. The purpose of this narrative review of the literature was to examine the current evidence on alcoholism and the consequences on oral and general health, in addition to implications to enhance dental hygiene practice for this population. The research question guiding this review was, “What are the implications of alcoholism on oral and general health?”
METHODS
Inclusion Criteria
This review of the literature sought articles about alcoholism and its impact on oral health, the oral microbiome, and general health. The student investigator (SI) and faculty principal investigator (PI) developed the inclusion/exclusion criteria based on the student’s literature review paper from an assignment in the dental hygiene program at the University of Minnesota School of Dentistry. The initial inclusion/exclusion criteria were reviewed by two additional study team members and feedback was provided. After review of the provided feedback, it was determined the review of literature inclusion criteria would focus on US or European evidence in the themes of general health, oral health, screening tools and education, periodontal diseases and conditions and cancer. To meet this inclusion criteria, studies were included if they were with US or European populations and alcohol use as it relates to: caries, periodontitis, oral microbiome, cancer, any general health, mental health, or oral health conditions. Alcohol use and patient education interventions of motivational interviewing, oral self-care, or screening tools for alcohol use were also included. Research designs were limited to randomized studies, clinical trials, observational studies, meta-analysis, systematic reviews, reviews, systematic reviews and reviews included in the search.
Exclusion Criteria
Exclusion criteria were no reference to alcohol use or persons with alcohol use or AUD, position papers or policy papers on alcohol use, studies on knowledge, attitudes, or perceptions of alcohol use. Studies on alcohol use related to academic outcomes, misuse, impact on genes or DNA, or alcohol as it relates to fetal alcohol syndrome. Studies that were published only as a conference or proceeding abstract were also excluded.
Search and Screening
A search was conducted on January 31, 2024, using a combination of controlled vocabulary and natural language to capture the concepts of alcoholism, oral health conditions, and general health. An initial search was developed for Medline (via Ovid) and then translated to Cinahl, Scopus, and Web of Science Core Collection. Search results were limited to the last seven years (2016-present), humans, and English language. The search strategy was created by a health sciences librarian with expertise in supporting evidence synthesis. Results were then exported to EndNote 21 (Clarivate Analytics) for deduplication and uploaded to Rayyan, an online tool designed to assist in the screening process. Two reviewers (SI and PI) independently screened titles and abstracts against the inclusion criteria. An in-person meeting occurred for the two reviewers to discuss conflicts until an agreed consensus. Articles that met the inclusion criteria from this first round of screening were added to a new Rayyan project for a second set of two different reviewers from the study team to independently screen titles and abstracts. An in-person meeting occurred to discuss conflicts with the faculty PI until consensus was achieved. Full texts were pulled for the remaining articles.
RESULTS
The search identified 406 articles after duplicates were removed. Reviewers excluded 384 articles in title and abstract review with 22 articles meeting the inclusion criteria for this review. Study results were categorized into five domains applicable for dental hygiene practice: general health (n=6), screening tools and education (n=4), oral health (n=4), periodontal diseases and conditions (n=4), and cancer (n=4). Articles in this narrative review were heterogenetic due to the variation of study designs, methods (participant selection and interventions), outcomes measured and statistical analysis. Table I provides the characteristics of the studies (n=22) included in the review.
Study Characteristics
General Health
Six articles related to general health included a cross-sectional survey,11 prospective cohort study,12 two observational clinical trials,13,14 a systematic review meta-analysis,15 and a retrospective analysis16 (n=6). An association between alcohol use and adverse cardiovascular events, including ischemic heart disease was identified in the literature.12,16 Further, a synergistic effect occurs when there is alcohol use in combination with smoking, which causes adverse cardiovascular events and renal events.12 However, wine consumption was found to have an inverse relationship on cardiovascular mortality.15 Other conditions associated with very high drinking levels of at least 100 grams of alcohol per day include: ischemic stroke, hemorrhagic stroke, liver cirrhosis, pancreatitis, sustained from traffic accidents and other injuries.16 Notably, individuals with this high level of alcohol use account for 54% of liver cirrhosis cases, 44% of pancreatitis cases, 41% of oral and pharyngeal cancers, 24% esophageal cancer, 17% colorectal cancers, and 10% of hemorrhagic stroke cases.16 Researchers found that having a chronic illness, such as diabetes or poor physical health, was a deterrent for high alcohol consumption at later ages (65 years or older).11
Microbial dysbiosis has also been identified in the gut microbiome14 and in the respiratory tract13 in individuals with AUD when compared to healthy controls.13,14 Ames et al. reported heavy drinking is associated with reduced gut microbiome diversity, resulting in chronic diseases.14 Samuelson et al. confirmed a significant difference between the microbiome of the lungs, bronchial mucosa, and oropharyngeal cavity when comparing individuals with AUD to controls, increasing the risk for infectious susceptibility, such as community-acquired pneumonia and acute respiratory distress syndrome (ARDS).13 Numerous gram-negative bacteria were identified in individuals with AUD at significant levels in the respiratory tract, including Prevotella, Neisseria, Porphyromonas, Veillonella, Haemophilus, and Actinobacillus, in addition to others.13 In the gut, significant levels of Streptococcus, Prevotella, and Veillonella were found in individuals with AUD.14 Notably, seven oral/gut bacteria were found (Actinomyces, Bifidobacterium, Dialister, Granulicatella, Lactobacillus, Megasphaera, and Veillonella) in this population.14 The clinical implications of persistent gram-negative pathogens increased the risks of pulmonary inflammation, chronic illness, and periodontal diseases.13,14 Ultimately, this is due to an increased immune response due to chronic antigen stimulation.13,14
Further investigation is necessary to determine the long-term implications of microbiome differences in the gut and respiratory tract,13,14 as well as the impact on mortality and morbidity resulting from cardiovascular events in individuals with AUD.16 Prevention strategies for cardiovascular events and renal disease are crucial to mitigate risk increase due to AUD.12 Future research is needed to standardized definitions and classification systems to measure heavy alcohol consumption to determine the risk on general health.11
Screening Tools and Education
Of the four studies for screening and education tools (n=4), two were in a dental setting.17 One was a two-armed randomized clinical trial,17 two articles were systematic reviews18,19 and one was a review.20 Tevik and colleagues systematic review of 105 articles reported the most commonly used questionnaires for alcohol consumption were the quantity-frequency (QF) questionnaire and the Alcohol Use Disorders Identification Test (AUDIT/AUDIT-C).18 Ntouva et al. suggested the AUDIT-C for a screening tool in the dental setting to identify excessive alcohol intake.17 As for education, Satpathy concluded the Transtheoretical Model of Behavior Change was the ideal framework to provide individualized support for alcohol cessation.20 A systematic review including 7 studies reported mindfulness-based interventions including clinicians being intentional to support without judgment of the alcohol use behavior; allows the individual to connect their behaviors and emotions to cope with the stressors (i.e., depression) enhancing their alcohol craving.19 Additional evidence is needed on effective screening tools and education methods for individuals with AUD in the dental setting.
Oral Health
Four articles related to AUD and oral health included a cross sectional study21 and a review22 that explored the effect of alcohol on one’s oral health generally (n=4). The epidemiological study23 and systematic review24 were specific to dental health changes including bruxism and tooth erosion. Individuals who abused alcohol were significantly more likely to have higher plaque scores (Silness-Loe plaque index), higher decayed, missing, and filled teeth (DMFT), and higher community periodontal index (CPI) scores than the control group.21 In addition, individuals with AUD have significantly poorer oral hygiene,21,22 hypersensitivity, traumatic injuries, and soft tissue lesions,22 in addition to higher rates of bruxism symptoms including tooth wear23,24 and reports of temporomandibular disorders (TMD).24 The combination of alcohol use with smoking and poor oral hygiene increased negative dental health outcomes.21 Further, excessive alcohol impaired the ability to maintain appointments with dental providers due to mental health struggles.22 A review by Ng and Ouanounou identified that up to 75% of individuals over the age of 65 use medications that interact with alcohol, such as opioids and central nervous system (CNS) depressants, and up to 19% use alcohol simultaneously, enhancing the risk of oral diseases.22 Multidisciplinary approaches and personalized interventions are required to reduce poorer dental outcomes in individuals with AUD.21–24
Periodontal Diseases and Conditions
Two articles discussed the causal association of AUD to periodontal disease,25,26 one article on necrotizing periodontal diseases,27 and one on peri-implantitis.28 A systematic review and meta-analyses of four systematic reviews and nine reports from seven cohorts concluded alcohol use increases the occurrence of periodontal diseases regardless of the study design by 0.4% for each 1g/day use of alcohol consumption.25 However, a high level of bias was identified to obtain these outcomes including the identification and selection of the study, data collection, and synthesis of findings.25 Further, no statistical significance was yielded for risk of periodontal diseases for individuals with AUD compared to non-AUD individuals.25
A 2016 clinical trial compared subgingival biofilm samples of 25 alcohol dependent vs. 25 non-alcohol dependent individuals with a diagnosis of chronic periodontitis (minimum of Stage II periodontitis).26 Although similar pathogenic bacteria were identified in both groups, the alcohol dependent group presented with higher levels of Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf), Treponema denticola (Td), and Aggregatibacter actinomycetemcomitans (Aa).26 Statistical significance was yielded for Pg (0.01), Td (0.01), and Aa (0.00) with higher concentrations of Pg, and Tf in pockets <4mm, suggesting worse periodontal health due to pathogenic bacteria.26
Individuals with AUD suffer from more predisposing factors of malnutrition and immunosuppression putting them at risk for necrotizing periodontal diseases.27 Tkacz et al. reported two case studies of untreated necrotizing gingivitis (NG) that advanced to necrotizing stomatitis (NS) as a result of malnutrition and immunosuppression from secondary alcohol misuse.27 Further, a consensus report of an international working group for peri-implant diseases determined alcoholism of 5 units per day (x 2.3) has been identified in the literature as a factor for implant loss.28 The prevalence of periodontal diseases and conditions for individuals with AUD needs further investigation.
Cancer
The four articles pertaining to AUD and cancer included a retrospective registry study,29 a epidemiological study,30 a retrospective clinical trial,31 and a review (n=4).32 Mons et al. reported one in every 50 cases of cancer is due to excessive alcohol consumption.30 A 20-year retrospective registry study reported the leading cancers for individuals with AUD were of the liver, lungs, pancreas, esophagus, colon, kidney, stomach, mouth, larynx, tongue and pharynx.29 A higher association of head and neck cancers (HNC), including the lip, tongue, pharynx, larynx, esophagus, have been reported in individuals with AUD.32 One study reported a higher frequency of secondary oropharyngeal cancers in men (oropharynx (20%), larynx (20%), and oral cavity (16%)) were associated with alcohol and tobacco use.31 However, this study did not stratify participants by age, sex, alcohol or tobacco use; therefore the authors were unable to determine if the secondary cancers noted were not enhanced by tobacco use or the Human Papilloma Virus (HPV).31 Additionally, findings from Kawakita et al. supported the existing literature that the interaction between genetic polymorphisms and alcohol metabolizing enzymes specific to the individual, impact the prevalence of HNC which also varies by ethnicity.32 More research is needed on the impact of alcohol consumption on HNCs.31,32
DISCUSSION
The rising occurrence in AUD impacting all genders, races, and ethnicities warranted this narrative review.1 Existing research on this topic is limited, particularly in populations within the US. Although major gaps remain in the literature for individuals with AUD, the evidence in this narrative review, in conjunction with the existing literature, can be combined to draw evidence-based conclusions to apply to dental hygiene professional practice.
Alcohol significantly increases one’s risk of morbidity and mortality associated with various health conditions, chronic inflammation12,14,16 and increases the risk of secondary cancers.3,4,6,8,31,33–35 Individuals with AUD double their risk of cardiovascular events when there is preexisting hypertension and tobacco use.12 Additionally, the microbial dysbiosis identified in the gut,14 the respiratory tract,13 and in the subgingival biofilm, specifically the keystone pathogens, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, is concerning.26 This review identified that both Prevotella and Veillonella were found in the gut14 and the respiratory tract13 and seven bacteria (Actinomyces, Bifidobacterium, Dialister, Granulicatella, Lactobacillus, Megasphaera, and Veillonella)14 were identified in the oral/gut flora in individuals with AUD.
The consequence of increasing levels of gram-negative bacteria in the body mounts an inflammatory response. Bacterial lipopolysaccharides (LPS) are recognized as foreign molecules and an immune response is elicited, designed to eliminate the bacterial intruder.36 The immuno-inflammatory response causes the release of inflammatory mediators including acute phase reactants and a variety of cytokines, which when chronically elevated are associated with various systemic conditions.37,38
The etiology of periodontal disease is biofilm consisting of organized oral pathogenic bacteria, infecting the gingiva causing a release of inflammatory mediators.39 However, this narrative review found that individuals with AUD and periodontal diseases have not been well investigated in the literature. Oliveira et al. reported that the non-significant findings of AUD with periodontal disease is a result of population “biases in alcohol measurement and classification.”25 They concluded alcohol use is part of a contributing causal mechanism escalated by biological gender differences and psychosocial cultural norms attributing to periodontal diseases.25 Statistically, men have an increased prevalence for periodontal diseases40–45 and alcohol use may differ culturally for males as compared to females.11,25,46–49 This may explain why there are more periodontal diseases associated with men who suffer from AUD. Further, individuals with AUD are commonly at a higher risk of stress,50–52 tobacco use,53–56 malnutrition,57–61 and immunodeficiency;3,6,7,27 all predisposing factors for necrotizing periodontal diseases.62 In addition to microbial dysbiosis26 and presence of oral flora, P. intermedia, and Treponema, Selenomonas and Fusobacterium species, cultured in individuals with necrotizing periodontal diseases.62,63
Poor oral hygiene and lack of oral self-care is prevalent among individuals with AUDs.21,22,55,56,64–67 Often there is a low motivation to perform oral or other self-care behaviors.21,22,56,64 This prevalence of poor self-image64 and mental health challenges,49,56,68 suggests an opportunity for interdisciplinary care with dental hygienists. The evidence that individuals with AUD are at increased risk of poor oral health outcomes,21,23 increased occurrences of periodontal diseases,9,25–28,55,67,69–73 higher rates of DMFT, symptoms of TMD, and severe erosion of tooth structures21,23,67,74,75 demonstrates the critical role dental hygienists can play in providing care for this population.
There is a need for a screening tool for alcohol abuse in routine dental hygiene care to reduce risks of poor oral and general health outcomes, as identified by this review of the literature. Existing literature consistently calls for timely interventions to improve individuals’ quality of life and prevent the progression of organ damage for individuals with AUD.12,14,16 Therefore, the integration of alcohol screening tools and adequate referral resources are crucial to providing evidence-based oral health care. However, there is not a reliable screening tool specifically designed for use in dental settings to screen individuals at risk for AUDs. Currently the AUDIT-C is supported as the most reliable screening tool available.17,18,76 The AUDIT-C is a three-item questionnaire, making it an efficient, easy to use screening tool; higher scores indicate drinking is affecting the individual’s health and safety.76 Future research is needed to determine the feasibility of using the AUDIT-C as a screening tool in dental settings for patients at risk of health and safety hazards due to alcohol use.
According to the Commission on Dental Accreditation (CODA), dental hygiene education programs must include health education and preventive counseling (Standard 2.8).77 Currently, many dental hygiene education programs include motivational interviewing (MI), a patient-centered counseling approach to support positive lifestyle behaviors.78–80 The inclusion of dental hygienists, as an integral part of the health care team, to provide education and counsel individuals with AUDs through MI was identified in this narrative review.
As preventive specialists, dental hygienists have a unique role in recognizing and managing AUD, and its related conditions. Within the dental hygiene scope of practice, professionals routinely screen for cardiovascular disease, cancers, precursor lesions of the head and neck, provide tobacco cessation, nutritional counseling, educate patients about their risk factors for oral disease, and otherwise support their patients’ health and wellbeing.10,81 The value of this expertise was highlighted by Mons et al., which discussed advising and supporting patients as a key cancer prevention strategy.30 Further, Kuhlin et al. discussed the importance of routine intraoral and extraoral examinations and cancer screenings in the dental setting, where a dental hygienist often sees their patients at least twice per year, providing an opportunity to monitor for the development of secondary cancers related to alcohol use.31 According to Sender-Janeczek et al., future research involving individuals with AUD should mandate oral health behavior interventions due to the complexity of AUD and its association with systemic disease periodontitis.26 The importance of patient education regarding oral self-care is also seen in Meyle et al. as adequate biofilm removal is critical to the prevention of peri-implantitis.28 Thus, dental hygienists have the potential to provide a crucial role in screening and patient-centered counseling for the prevention and management of health conditions, chronic inflammation, and secondary cancers associated with excessive alcohol consumption.3,4,6,8,10,12,14,16,31,33–35,81
A major limitation of this narrative review was the number of studies included, and the limitations reported in the studies (n=22, Table I). The inclusion criteria of US or European populations only for this narrative review narrowed the available evidence. Future research is needed to determine if there is a safe amount of alcohol consumption. According to the World Health Organization there is no safe amount of alcohol consumption,5 however evidence in this review showed that wine consumption has an inverse relationship on cardiovascular mortality.16 Additionally, future research on general health, cancers, and oral health needs to be expanded on AUD among US populations along with the role of dental professionals in the prevention and management of oral and general health issues related to AUD. Guidelines for research may include the efficacy of screening tools, patient education and counseling in the dental setting. Specifically, future research is warranted to explore the unique role of dental hygienists in the prevention, screening, education, and counseling of patients with AUDs.
CONCLUSION
The overarching finding of this narrative review was that alcohol consumption significantly increases one’s risk of morbidity and mortality risk due to its association with chronic health conditions, inflammation, and secondary cancers. Poor oral hygiene is prevalent for this population, which increases the risk of DMFT, periodontal, and peri-implant diseases. Although the AUDIT-C is a reliable screening tool to identify hazardous alcohol consumption, it is not commonly used in dental settings as a risk assessment tool. Further development and assessment of AUD screening tools is needed to increase applicability in the dental setting to support individuals with AUD.
IMPLICATIONS FOR DENTAL HYGIENE PRACTICE
Alcohol consumption significantly increases an individual’s risk of morbidity and mortality associated with various health conditions in addition to doubling the risk of cardiovascular events.
Individuals with AUD are commonly at a higher risk of stress, tobacco use, malnutrition, and immunodeficiency. These factors coupled with microbial dysbiosis increase the risk of periodontal diseases.
This review of the literature highlights patient care improvements for individuals with AUD and strategies for supporting the health and well-being of individuals with AUD.
Footnotes
NDHRA priority area, Population level: Epidemiology (health services).
DISCLOSURES
The authors have no conflicts of interest to disclose.
This research was supported by the National Institutes of Health’s National Center for Advancing Translational Sciences, grant UL1TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences.
- Received June 18, 2024.
- Accepted August 19, 2024.
- Copyright © 2025 The American Dental Hygienists’ Association
REFERENCES
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