June 6, 2016
by Lynsey Millar, BDS (Hons.), MFDS, RCPSG
Alcohol and drug dependence is an ongoing worldwide problem. The effects of alcohol kill 3.3 million people every year. This amounts to 5.9% of all deaths.1 Alcoholic liver disease is at an all time high level, and alcohol is now the third leading cause of ill health after tobacco and high blood pressure in England.2 In 2013, data from the World Health Organization’s Global Health Observatory shows that the prevalence of past-year use of alcohol in Canada (77.1%) was slightly lower than that reported in the United Kingdom (83.9%).3
A low risk drinking guideline issued by the Canadian Centre on Substance Abuse recommends that women have no more than 10 drinks a week, with no more than two drinks a day, most days. For men, it advises no more than 15 drinks a week, with no more than three drinks a day, most days. It recommends planning non-drinking days every week to avoid developing a habit.4 However, it was reported that in Canada in 2012, among people who consumed alcohol in the past 12 months, 18.6% (representing 14.4% of the total population) exceeded this guideline.5
In England in 2013/2014, around one-third of adults had used drugs at some point in their lives.6 Statistics from 2007 showed the prevalence of drug use to be 9.2% and the prevalence of dependence to be 3.4%.7 Aside from alcohol, the most common drug of dependence is cannabis.7 A large proportion of people use multiple drugs.7 In Canada in 2013, the use of at least one of six illicit drugs in the past 12 months (cannabis, cocaine, or crack, speed, ecstasy, hallucinogens or heroin) was reported by 11% of Canadians (3.1 million).8
Drugs and alcohol are examples of psychoactive substances: “substances that when ingested affect mental processes, i.e. cognition.”9 Their use can lead to dependence, which is defined as “a cluster of cognitive, behavioural and physiologic symptoms that indicate a person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences.”9 Addiction is often used interchangeably to describe this.
Given the number of individuals who are using alcohol and drugs, it is inevitable that they will present for dental treatment, whether it be due to an acute dental problem or a desire for comprehensive care. Dentists may have a role in assisting a patient to seek help to initiate recovery, or to maintain dental health whilst in rehabilitation, thus contributing to their overall health.
A combination of factors makes this group at high risk from dental disease. Dry mouth is common10, and this combined with a poor diet involving a high volume of sugar, can result in caries. There is also a risk of periodontal disease and chaotic lifestyles can mean oral hygiene falls low on the priority list. Research has shown that there is a high incidence of self-reported poor oral health within these individuals.11 They have varying dental needs, and as professionals we should endeavor to meet these needs.
This paper aims to provide an overview for general dental practitioners (GDPs) of the challenges that can arise in treating patients who are dependent on drugs or alcohol, alongside some suggestions for meeting these challenges. General issues are taken into consideration first, and then a focus is made on each of the most common substances, together with their implications in dentistry.
Access to Dental Care
Substance dependent patients may find it difficult to access dental care. Barriers include low priority of oral health compared with drug use, fear of dentists including needle phobia, self-medication and chaotic lifestyles.12 In addition; they may fear judgment or prejudice from the dental team.
The optimum setting for dental treatment depends on the individual patient and the services available. For many patients, treatment in a general practice environment is appropriate. Sometimes, onward referral for treatment in hospital services where additional treatments such as sedation or general anaesthetic are available may be preferred. There is a known causal link with substance use and homelessness.13 This may present difficulties in attending services. Therefore, in some areas dental care may be provided for these groups via a mobile dental unit, as is the case in NHS Tayside, Scotland.
A detailed social history is key when assessing risk of oral disease and dental motivation and can aid treatment planning. The stigma that is often attached to drug and alcohol use means that patients may not freely admit to using such substances. Thus, sensitive questioning without judgement is required regarding alcohol consumption: including number of units consumed per week; the use of drugs – prescription or recreational – along with quantity and duration; smoking status and living arrangements.
Many substance dependent patients lead chaotic lives and this, in turn, can negatively affect attendance and motivation towards oral health and self care. These factors contribute to the oral problems in these patients and often have a greater impact than the direct effect of drugs. If patients are enrolled in an addiction program, it is possible that a key worker will have been assigned to them. Key workers can be instrumental in encouraging their clients to attend appointments, or in some cases, accompanying patients to appointments. If patients are not receiving help – referral can be made to their general medical practitioner (GMP) or appropriate services with consent from the patient.
Consent and Treatment Planning
Gaining consent may present an issue whilst treating the dependent patient. Drug users share risk factors for mental health issues and many of these patients may have fluctuating capacity, or have the ability to consent to some treatment, but lack the capacity to consent to more complex treatment. If a patient presents for treatment whilst under the influence of drugs or alcohol, then it is unlikely that they will have capacity and treatment should be postponed in this situation.
If you suspect that a patient does not have capacity to consent, for example a patient with alcohol related brain damage, there may be a substitute decision maker who can make decisions on their behalf.
The Royal College of Dental Surgeons of Ontario (RCDSO) suggests that in any circumstance where it is determined that any adult is incapable, you should record the following in the patient record:
• the circumstances which gave rise to the forming of that view;
• the advice that was provided to the patient
• the name and the relationship of the person whose consent was obtained in substitution for the consent of the patient;
• whether the substitute decision-maker has been given a power of attorney for personal care for the patient.14
When formulating a treatment plan, patient expectations should be sought and it is important to be realistic about what is achievable early on. The patient may present with unexpected symptoms requiring additional treatment during a course of planned treatment, and so a flexible approach should be adopted. An initial “stabilisation” phase in the treatment plan can be beneficial.15 It may involve the removal of active caries and placement of provisional restorations, often via a quadrant approach. For lesions close to the pulp, consideration can be given to stepwise excavation. Pulp extirpation followed by a provisional restoration can be carried out for any teeth requiring root canal treatment. It ensures that lesions are protected, should the patient fail to return. This period also provides an opportunity to work together with the patient to ensure that oral hygiene and dietary factors are under control, prior to placement of definitive restorations. If contemplating complex treatment, consideration must be given to future maintenance; taking into account patient’s motivation, compliance with preventive measures and likelihood of attendance for continuing care.
Pain and Anxiety Control
This can be a challenge and dependent patients often have low pain thresholds. In addition, many drugs mask dental pain and when patients stop using drugs, they require dental treatment to resolve the symptoms that present.
Many of these patients are dentally anxious. Methods of pain and anxiety control should be considered and all options should be discussed with the patient. The use of behaviour management techniques can alleviate anxiety, establishing trust and making the patient feel understood. It is thought that opioid users may exhibit resistance to local anaesthetics (LA)16 and pain control can be difficult. Adjuvants such as sedation or GA may be considered.
Sedation may be an option for the patient in rehabilitation; however, it should be used with caution and may require referral to anaesthetist led services. Venous access may pose a difficulty due to collapse of veins in a patient with history of intravenous drug use. These patients may have developed a tolerance to effects of sedative drugs and require large doses in order for adequate anxiolysis to be achieved.
Alcohol and opioids have a synergistic effect with sedative agents and so IV sedation should be avoided if the patient is using these substances. Disulfiram inhibits metabolism of benzodiazepines and leads to increased sedative effects if used together.17
Dependent patients may request prescriptions for medication when it is not appropriate. Suspicions should be aroused if they claim to be allergic to over the counter pain relief or describe pain which is not consistent with the clinical findings. They may attend late for appointments so that there is limited time to carry out any active treatment or refuse to have treatment carried out in the hope of obtaining a prescription as an alternative.16,18
Prevention is key for all patients and may include the following:
• High strength fluoride toothpaste
• Fluoride varnish application
• Alcohol free fluoride containing mouthwash
• Tooth mousse – either direct application or with a tray
• Dietary and oral hygiene instruction
Alcohol is a causal factor in more than 60 medical conditions including cancers, mental and behavioural disorders, gastrointestinal disorders, lung diseases, cardiovascular diseases and cirrhosis of the liver.19
One particularly relevant to dentistry is that of alcoholic liver disease including fatty liver, alcoholic hepatitis, and in later stages, cirrhosis.
Several signs may be visible in the clothed patient which should arouse suspicions of liver disease:20
• Spider naevi
• Sialosis – bilateral enlargement of the parotid glands
• Oedema – ankle oedema or acites
• Itching of skin
• Dupuytrens contracture – bending of one or more fingers towards the palms
• Finger clubbing
• Tremor in hands
If a patient suffers severe liver damage, there may be a bleeding risk during surgical procedures (i.e. extractions) due to decreased synthesis of clotting factors, usually produced in the liver. Careful questioning should be undertaken prior to treatment with regard to previous episodes of bleeding following surgery/dental treatment, and any bruising tendencies.
Liaison with patients GMP/gastroenterologist may be necessary before undertaking dental extractions or other surgical procedures. Assessment of full blood count, coagulation screen and liver function tests can be done preoperatively in order to risk assess and decide if surgical treatment is safe. If there is concern over bleeding risk, then the patient should be referred to the local oral surgery or maxillofacial unit.
Care should also be taken when administering LA that is metabolised in the liver – doses should be kept to a minimum. Even two cartridges of LA may trigger signs of CNS toxicity if liver disease is severe.20 In addition, sedative agents and general anaesthetic agents pose a risk of toxicity.
Non-steroidal anti-inflammatory drugs, miconazole, metronidazole, erythromycin and tetracyclines should all be avoided in severe liver damage. Doses of fluconazole and paracetomal should be reduced.20
Many recovering alcohol dependent patients may be on disulfiram (antabuse). It is important to be aware that a psychotic reaction has been reported when disulfiram is given with metronidazole.17 In addition, alcohol-containing substances should be avoided including chlorohexidine mouthwash and benzydamine spray/mouthwash.
In Canada, over 400 liver transplants are carried out each year.21 Prior to transplant, patients should undergo a full dental assessment and active disease should be treated prior to transplantation, as any areas of infection could pose serious risk whilst the patient undergoes immunosuppressive therapy.22,23 Dental treatment following the transplant should be postponed for three months, if elective, and may require antibiotic cover, and liaison with the medical consultant should facilitate this.22 There is a marked increased incidence of almost all carcinomas in those who have undergone a transplant, in some cases this is related to risk factors prior to the transplant, especially alcohol use, and in others to long term immunosuppression.22
Dental problems experienced by those who are alcohol dependent include erosion. This is due to the acidic nature of alcoholic beverages and also the increased incidence of reflux and recurrent vomiting. Nocturnal bruxism is common24 and may contribute to non-carious tooth surface loss. Dry mouth is common secondary to dehydration and vomiting. Glossitis, angular cheilitis and recurrent apthae are also seen. Poor wound healing secondary to immunosuppression can occur following extractions.
Remember there is an oral cancer risk, especially if the patient is a smoker. Patient education is key regarding the increased risk and any suspicious lesions should be referred for specialist opinion. There is also a risk of maxillofacial trauma resulting from violence1 and falls.
As mentioned in the consent section, alcohol related brain damage (ARBD) can be an issue for practitioners. The term ARBD encompasses a range of conditions, including Wernicke’s encephalopathy and Korsakoffs syndrome.25
Wernicke’s encephalopathy describes acute episodes whereby the patient may be confused, with impaired consciousness and mobility issues. If treatment is delayed, or not carried out at all, then this can result in the chronic condition Korsakoff’s psychosis that is characterised by permanent memory deficits. The two conditions are seen together as part of the same condition called Wernicke-Korsakoff syndrome.25
Other labels including alcohol related dementia and alcoholic dementia relate to excess alcohol consumption, which results in a less specific cognitive impairment.25
There are three main forms of cannabis, namely, marijuana, hashish and hash oil. Marijuana is the most commonly used and it is usually smoked.26
Acute effects are varied and usually last for up to three hours. They can include: excitement, euphoria, apprehension, and disorientation, often followed by tranquility then fatigue.24
It has been suggested that there may be an increased risk of oral cancer relating to cannabis use, however there is no consistent evidence to implicate cannabis use as a causative factor.27 One of the most significant effects of cannabis use is psychosis including schizophrenia.24,28,29 Impairment in memory and cognitive function has been observed in heavy users.30 Dentally, xerostomia is common and caries is often seen.24
Heroin is a highly addictive opioid that can be injected intravenously, smoked, or snorted.31 It’s immediate effect is that of euphoria, lasting for several hours, then a sedative state occurs due to central nervous system depression, which includes analgesia.24
It is associated with a number of morbidities including psychosis, respiratory depression, constipation, orthostatic hypotension and if used intravenously, blood borne viruses including Hepatitis B and C, and HIV, as well as infective endocarditis.24 The most prevalent blood borne virus is hepatitis C and among people who inject psychoactive drugs (including heroin), around two in five are infected with it; of which half are undiagnosed.32 It goes without saying that standard infection control procedures should be adopted for all patients in all instances.
Methadone is a synthetic opioid and is the most commonly used drug for treatment of dependence. It is delivered orally as a liquid daily in doses of 60-120 mg17 and its use may be supervised or unsupervised. Suboxone delivered as a sublingual tablet is also being used as an alternative. Dental neglect including caries affecting the cervical margins, acid erosion, and periodontal disease is often observed in this group of patients.
Debate exists as to whether the sugar in methadone directly causes decay or whether it is a result of xerostomia, poor diet and lack of oral hygiene. There is evidence that opioids increase sugar cravings33 and the resulting decay is possibly a combination of said factors.
Targeted prevention for this group includes requesting prescription of sugar free methadone and encouraging brushing prior to methadone, delivery through a straw, rinsing afterwards and avoidance of brushing for 30 minutes following methadone consumption.
Cocaine is an addictive drug that is usually snorted, and can also be smoked (crack cocaine) or injected intravenously. Initial effects appear in a matter of minutes and include euphoria and mental clarity. Large doses can produce hallucinations and paranoia.24
Cocaine has also been known to trigger cluster headache,24,34 bruxism,35 erosion and dry mouth are also prevalent. Around 5% of patients have nasal septum perforation due to local ischaemia and subsequent necrosis.35 Problems with sinusitis and nosebleeds are frequent. More rarely, palatal perforation is seen, posing severe problems with patients in eating and speaking. If cocaine usage is ceased, surgical intervention may be appropriate in an attempt to gain closure. Alternatively, an obturator may be constructed to fill the defect.34,36
Adrenaline containing LA should be avoided until at least six hours following cocaine use due to risk of interaction leading to acute cardiac emergencies.24
New Psychoactive Substances (NPS)
New Psychoactive Substances (NPS) have been defined as: “psychoactive drugs which are not prohibited by the United Nations Single Convention on Narcotic Drugs or by the Misuse of Drugs Act 1971, and which people are seeking for intoxicant use”37 Otherwise known as legal highs, they are a recent global public health issue. The introduction of the ‘Psychoactive Substances Act’ in England and Wales will come into effect in May 2016, prohibiting trade of ‘legal highs.’ Eighty-one different substances were detected in Europe in 2013. Examples include: mephedrone, ketamine, spice, and benzofury.37 They are often made up as mixtures of legal and illegal ingredients, with the aim being to mimic the effects of controlled drugs. They are commonly sold online, often labeled as “plant food” or “bath salts.” There is little evidence available on long term health effects of these but it is thought that NPS can cause various conditions – both physical and psychological and that they are just as serious as other drugs and can cause death.38 There is currently no evidence describing dental implications but it is important for dentists to be aware of these increasingly used substances.
There is a need for multidisciplinary teamwork in the care of substance dependent patients, and dentists have a key role to play in this. As more new psychoactive substances arise, and as the burden of alcohol becomes increasingly apparent, especially in younger generations,39 there will continue to be challenges for GDPs in treating such patients.OH
Lynsey Millar, Senior House Officer in Oral & Maxillofacial Surgery, Monklands Hospital, Scotland. Email: firstname.lastname@example.org.
Oral Health welcomes this original article.
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