8 - Substance misuse: dental implications

Question 1

6

What is the role of the GDP in patients with substance misuse?

Answer 1

• recognise substance misuse
• signpost to addiction services
• emergency dental treatment
• maintenance of dental health
• realistic treatment planning
• empathy

Question 2

8

How do you recognise substance misuse?

Answer 2

• loss of reliability
• mood and behaviour changes
• subjective symptoms with no objective evidence
• requesting specific drugs
• deterioration in appearance and hygiene
• tremors
• pupillary change
• puncture marks, scars or pigmentation over veins

Question 3

4

What is important in the social history for a patient with substance misuse?

Answer 3

• alcohol consumption
• drug consumption, including when last taken “for safety of procedure”
• smoking status
• living arrangement

Question 4

5

What are the medical implications of substance misuse?

Answer 4

• infection including STI, BBV, TB
• health neglect
• chronic liver disease (impaired drug metabolism, increased bleeding risk, impaired wound healing)
• infective endocarditis
• venous thromboses

Question 5

How do you manage consent in substance misuse?

Answer 5

• capacity is unlikely if the person is under the influence of drugs or alcohol
• postpone treatment if possible

Question 6

4

Describe the treatment planning in a substance misuse case.

Answer 6

• flexible approach, anticipate unexpected symptoms between appointments
• initial stabilisation required
• prevention is key
• simple treatment eg ART or SDF

Question 7

What can cause LA resistance?

Answer 7

Opioid use

Question 8

What is the interaction between cannabis and LA?

Answer 8

• can cause prolonged tachycardia
• ideally patient should be at least 3 days drug free

Question 9

What is the interaction between alcohol and LA?

Answer 9

• most LA is metabolised in the liver
• multiple cartridges could cause CNS toxicity
• articaine is best option as metabolised in plasma
• avoid IDB in patients with poor coagulation

Question 10

4

How is sedation used in substance misuse?

Answer 10

• inhalation is safest
• can develop tolerance
• IV sedation has synergistic effect with alcohol and opioids so should be avoided
• can trigger relapse

Question 11

9

What are common presentations of substance misuse in the mouth?

Answer 11

• rampant caries on all tooth surfaces
• periodontal disease including necrotising conditions
• NCTSL
• masseteric hypertrophy
• hypo salivation
• poor OH
• opportunistic infection
• trauma
• oral cancer

Question 12

How can you adjust appointments for an alcoholic?

Answer 12

Morning appointments are better as they are least likely to be under the influence

Question 13

What is the link between Antabuse and metronidazole?

Answer 13

• disulfiram
• can have psychotic reaction if taken with metronidazole
• amoxicillin is indicated

Question 14

5

What are the dental implications of opiate use?

Answer 14

• trauma
• infective endocarditis
• oral neglect
• impaired drug metabolism
• enchanted sedative effect

Question 15

What is methadone?

Answer 15

• used to replace opiate and aid withdrawal
• high sugar content
• caries rate significantly high

Question 16

6

What advice can you give methadone users?

Answer 16

• use a straw
• drink water after consumption
• don’t brush teeth immediately after
• engage with dental services
• prevention is key
• sugar free suspension if possible

Question 17

5

What risks are associated with cannabis?

Answer 17

• oral cancer
• psychosis and schizophrenia
• impairment in memory and cognitive function
• xerostomia
• caries

Question 18

5

How can cocaine use present in the mouth?

Answer 18

• unusual ulceration on gingiva
• NCSTL
• caries
• orofacial pain
• palatal/nasal perforation in severe cases

Question 19

What is the interaction between cocaine and LA?

Answer 19

• adrenaline can have additive effect
• delay 6-24 hours