Some patients might reveal to you either a past or current use of substances such as recreational drugs or alcohol... but how does that affect dental care?
Which Substances can be Misused?
- Cannabis - the most commonly abused drug in the UK
- Cocaine - the second most commonly abused drug in the UK
- Alcohol
- Heroin/opiates
- Nitrous Oxide
- MDMA
- Ketamine
- Spice
- Poppers
- Over the counter medication e.g.opioids, benzodiazepines
What are the Oral Manifestations of Substance Misuse?
Oral manifestations of substance misuse can be very specific to the substance, or more general or as a consequence of the effect of the substance. For example, some substances cause sugar cravings or binges, which increases the risk of caries.
Some oral manifestations are:
- Caries
- Periodontal disease
- Xerostomia
- Oral cancer/precancerous lesions
- Soft tissue perforations (cocaine use)
- MRONJ/osteomyelitis
- Cluster headaches
- Tooth surface loss (attritive from grinding, erosive from vomiting/alcohol use)
- Oral ulceration
- Burns (poppers)
- Bleeding (alcohol)
- Halitosis (alcohol)
- Traumatic injuries (from accidents during intoxication)
Top Tips when Managing these Patients
1. Treat patients in the context of their lives right now
If the person is at a chaotic or unstable point in their life; perhaps their addiction is not under control, they don't have a stable place to live, or their mental health is really unstable, perhaps they only want to engage with emergency or ad hoc dentistry. Treat their expressed need so they are pain free and comfortable, and when they are ready to engage for comprehensive care, you will have gained their trust.
2. Tailor prevention messages
Are you able to adapt your prevention messages so they are relevant to the patient? If they are on methadone, advise them to rinse their mouth out or use sugar free gum afterwards to counteract the dry mouth effects. Can you prescribe high fluoride mouthwash for your patient to use if they frequently vomit after using alcohol
3. Work collaboratively
Make every contact count - if you can work together with Drug & Alcohol teams in terms of pathways, but also if you need support chaperoning patients or getting further information e.g. blood tests, advising sugar-free methadone.
4. Assess capacity
Just because a patient turns up to an appointment having consumed drugs or alcohol, doesn't automatically mean they lack capacity to consent. For many, they require their substance to be able to function and if you refused to see them after they've had a substance, you'll never actually get to treat them. Assess their capacity using the Mental Capacity Act's Code of Practice - even if they don't have capacity for treatment, are you able to do something to engage them like perform a check-up or give prevention advice?
5. Be wary of drug interactions with local anaesthetics and sedative agents
If patients have recently taken certain stimulants (cocaine, MDMA) there is a risk of interaction with adrenaline-containing local anaesthetics (hypertension, convulsions), so defer treatment.
Many substances, such as cannabis, stimulants, opioids, interact with midazolam sedation or make sedation unpredictable. Be cautious and offer alternatives (e.g inhalation sedation) if possible.
6. Listen to patient's pain!
Patient's pain thresholds might be very low if they are detoxing or have been switched to drug replacement therapy. They can be very sensitive to pain (for example even when delivering local anaesthetic), they might complain of toothache when coming off their substance as it had been masking their pain or they might require more than normal doses of local anaesthetic
7. Be aware of bleeding
Many of these patients will bleed and therefore you need to assess their risk when planning extractions. There is a high incidence of blood bourne viruses in IV drug users so they might have liver damage from hepatitis, or chronic alcohol excess will have caused cirrhosis of the liver.
Liaise with their medical teams for recent blood tests and ask the patients more about their bleeding. Do they bruise easily? For blood tests, Liver Function Tests (LFTs) will show deranged liver enzymes which are related to clotting factors, but I find that quantifying bleeding risk is more easily assessed by a INR, which will tell you how much longer it takes for a person to stop bleeding. Also consider local haemostatic measures, staging extractions and careful post operative advice. When in doubt, ask for advice from an oral surgeon or Special Care dentist.
To read more about drug misuse in dentistry, read one of my latest articles in Dental Update here.
If you have any questions about managing these patients, please leave comments below.
