Quick reference/description

The American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders (DSM–5)” states that “The essential feature of substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indication that the individual continues using the substance despite significant substance-related problems.” A diagnosis of SUD “is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria”.

The ICD-11 describes substance abuse disorders under chapter 6 (mental, behavioral, or neurodevelopmental disorders). This block contains a wide variety of substance use disorders that differ in severity—they include use disorders pertaining to problematic use of alcohol, cannabinoids, opioids, cocaine, sedative hypnotics, hallucinogens, tobacco and other stimulants.

Overview

Oral manifestations of SUD

Substance abuse affects all body systems negatively: it impacts appetite, heart rate and blood pressure, it induces psychosis through structural and chemical brain changes and it can lead to serious blood–borne infections such as HIV/AIDS, Hepatitis C. etc. … Baghaie et al. identified an association between poor oral health and substance abuse. Oral conditions in patients with SUDs such as poor oral hygiene, changes in salivary pH and cariogenic diets can lead to progressive caries and maxillofacial infections (Table 1).

Table 1 Effects of long-term substance abuse on systemic and oral health
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The complexity of the oral condition of patients with SUD presents a challenge for dental professionals. Patients are commonly difficult to manage due to their lack of compliance with treatment and instructions. A number of patients tend to be apprehensive about dental care resulting in non-compliance with appointments and avoidance in seeking dental care. The literature reports that SUD patients self-medicate for painful medical and dental conditions.

A clinical examination and a detailed medical history are vital for identifying patients with substance misuse/abuse problems. Many patients do not report the misuse of drugs, prescribed or otherwise. It is essential to practice non-confrontational medical history taking with “judgement-free” questioning of possible drug use and alcohol consumption. Soft tissue examination should be performed frequently due to the increased risk of oral cancer in patients who consume alcohol in large amounts. Periodontitis in young adults may suggest chronic marijuana use. Poor oral hygiene and a sugar-based diet are likely to present in the majority of patients with SUD who consequently develop extensive caries. A comprehensive evaluation is recommended to determine the extent the patient can actively participate in the dental treatment and treatment plans should be simple and feasible (Fig. 1). Dental management should prioritize pain and the prevention of orofacial infections over esthetic concerns.

Fig. 1
figure 1

Clinical photos and a panoramic radiograph of a 27-year-old patient with a history of methamphetamine use for a number of years. Prevention and early intervention are necessary in SUD to prevent irreversible damage to oral structures as seen in the photos below

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A multidisciplinary approach is essential for the coordination of dental treatment whenever pain control is necessary. Regular communication with the patient’s physician and pharmacist should be maintained and pain management is best coordinated with the patient’s physician to prevent poly-pharmacy, drug interactions and overdosing. Documentation is essential, as is careful treatment planning and patient engagement.

It is important for the clinician to remember that SUD is a chronic disorder like other chronic disorders including diabetes mellitus, hypertension and cardiovascular disease—successful dental treatment is only possible in a patient who is stable, treatment-compliant and is in the remission phase of the disease.

Materials/instruments

  • Medical history questionnaire that inquires about drug and alcohol use

  • Basic dental examination instruments

  • Dental radiographs

Procedure

Prior to commencing treatment on patients with SUD, practitioners should be familiar with a number of precautions (Table 2).

Table 2 The following precautions are recommended when treating patients with SUD
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Early medical intervention in patients with SUD is crucial for the prevention of permanent damage to systemic and oral health. Once a patient is in the recovery/remission phase, disease prevention and patient education are critical to maintaining good oral health and preventing further oro-dental deterioration. The importance of oral hygiene needs to be emphasized and basic oral hygiene steps should be regularly reviewed with the patient. Preventive measures including fluoride supplementation, prescription toothpaste and chlorhexidine use should be encouraged. Sugarless products like xylitol could potentially help substance abuse patients. Recommending the use of xylitol-containing gum or candies has shown good results in the prevention of caries helping regulate saliva pH. Furthermore, in patients who are not in SUD remission or not successful in their SUD therapy, Silver Diamine Fluoride (SDF) for caries control should be considered. SDF has been used outside the United States for many years for caries control and in 2014 it was cleared by FDA as a desensitizing agent. SDF arrests active carious lesions without local anesthetic in a noninvasive way, avoiding or delaying traditional mechanical removal of caries. SDF is indicated in treating caries in people who are unable to access dental treatment or tolerate conventional dental care.

Patients on buprenorphine/naloxone or methadone therapy (treatment for SUD) should be instructed to rinse their mouths with water immediately following tablet or liquid dissolution and consumption, respectively (Table 3). Patients should be advised to drink eight to ten glasses of water each day and avoid consumption of caffeine, tobacco and alcoholic beverages. Other recommendations include chewing sugar-free gum and drinking methadone through a straw.

Table 3 Treatment for substance use disorder
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Managing xerostomia in patients with SUD should be an integral part of the treatment plan: adequate hydration and the reduction of sugar consumption must be prioritized. Salivary substitutes, oral moisturizers and artificial saliva are recommended for patients with recurring xerostomia. For severe xerostomia and suspected salivary gland dysfunction, muscarinic-cholinergic agonist drugs such as pilocarpine stimulate salivary flow and may be prescribed in the absence of contraindications and drug interactions. There is limited information in the literature related to the treatment of bruxism and temporomandibular disorders as a consequence of SUD; fabrication and the regular use of bite splints or mouth guards is recommended on a case-by-case basis though patient compliance may be a limiting factor!

Pitfalls and complications

  • Only palliative and emergency treatment should be performed on SUD patients who are not in the remission/recovery phase. Multidisciplinary systemic and psychological management are essential prior to definitive dental treatment.

  • Definitive treatment is given to recovering patients and those in remission must include preventive measures to improve oral hygiene and reduce the risk and burden of oral disease.

The management of oral health consequences of SUD is complex. It is necessary to have collaborative efforts amongst health professionals during the recovery/remission phase. Oral health providers must be in communication with the patient’s medical providers when coordinating the delivery of dental treatment for the safety and well-being of the patient. Sequencing and re-evaluation of dental treatment are essential in patients who have not recovered from SUD. Dental professionals hold a unique position in the early identification of drug abuse and mitigating the associated risks of adverse oral effects.