Substance abuse

Question 1

What is the traditional theory on the pattern of addiction

Answer 1

• intense initial intoxiciation
• development of tolerance
• escalation in intake
• profound dysphoria, physical discomfort and somatic withdrawal

Question 2

What is the ‘reward’ pathway

Answer 2

• when activated by rewarding stimulus, informationt ravels from the VTA to the nucelus accumbens and then up to the prefrontal cortex
• dopamine mediated transmission allows us to feel pleasure

Question 3

How do drugs effect neurotransmitters

Answer 3

increased dopamina levels - euphoria
decreased levels of serotonin - decreased levels of contentment

Question 4

What does prolonged exposure to drugs of abuse result in

Answer 4

addiction via reward pathway
chronic exposure reduces sensitivity of brain to reward system

Question 5

What are features of drug dependance

Answer 5

• psychological - taking the drug knowing its harmful
• physical - symptoms if drug not taken
• withdrawal syndrome - symptoms following sudden withdrawal
• tolerance - repeated administration means they become less sensitive

Question 6

What are the risks of illicit drug use

Answer 6

• STI
• BBV
• TB
• smoking/alcohol risks

Question 7

What are injection related complications from drug use

Answer 7

• cellulitis
• abscess
• thrombophlebitis
• thrombosis
• embolism
• DVT

Question 8

What are the effects of cannabis

Answer 8

• euphoria
• slowed thinking and reaction time
• confusion
• impaired balance and coordination
• cough
• frequent resp infections
• impared memory and learning
• increased HR
• anxiety
• panic

Question 9

What are the effects of alcohol

Answer 9

• CNS depressant
• judgement, concentration and coordination
• effects are dose related
• eventually interfere with cerebellar function
• cause ataxia and motor coordination
• ultimately unconsciousness

Question 10

What are signs of substance misuse

Answer 10

• loss of reliability
• mood and behaviour changes - defensive and angry
• subjective symptoms
• requesting specific drugs
• progressive deterioration in personal appearance and hygiene
• tremor
• constricted pupils or dilated
• puncture marks, scars or pigmentation over veins

Question 11

What are barriers to accessing dental services for drug misusers

Answer 11

• fear of judgement
• low priority of OH
• fear of dentists
• self medication
• chaotic lifestyle
• poor attendance compliance
• cost

Question 12

What can help facilitate access for drug misusers

Answer 12

• key workers may be assigned if enrolled in addiction programmes
• key workers can encourage attendance and accompany px to appointments

Question 13

What are the medical implications of drug misuse

Answer 13

• increased rates of infection
• general health neglect
• oral health neglect
• chronic liver disease in alcohol abuse - impaired drug metabolism and bleeding risk
• BBV
• infective endocarditis
• venous thromboses

Question 14

Why may consent be an issue for this group

Answer 14

• issue for dependent px
• fluctuating capacity
• capacity unlikely when under the influence
• postpone tx

Question 15

What are examples of alcohol related brian damage

Answer 15

korsakoffs syndrome
similar to dementia

Question 16

How can LA be impacted in cannabis misusers

Answer 16

LA with adrenaline can prolong acute tacychardia

Question 17

What problems can LA pose for alcohol misusers

Answer 17

• liver problems
• lidocaine metabolzied in liver
• keep doses to minimum
• use articaine
• avoid IDB

Question 18

Why can sedation pose a problem to this group

Answer 18

• px may have developed tolerance to sedative drugs so larger doses required - refer to anaesthetist
• alcohol and opiod have synergistic effect with sedative agents –> avoid if px actively using substance
• GA and IV can trigger relapse
• venous access –> collapsing veins

Question 19

What are general dental implications of substance misuse

Answer 19

• rampant caries
• periodontal disease
• NCTSL
• masseteric hypertrophy
• hyposalivation
• poor OH
• opportunistic infections
• trauma
• oral cancer and mucosal lesions

Question 20

Why are px at risk of necrotizing periodontal diseases

Answer 20

• impaired immune system
• stress, BBV, smokers

Question 21

What appointment times should this group be given

Answer 21

morning as less likely to be under the influence
high chance of DNA however

Question 22

What are the effect of sedatives in alcohol users

Answer 22

risk of tolerance
have an addictive effect

Question 23

Why should GA be avoided in alcohol abusers

Answer 23

• risk of vomiting
• risk of inhalation of vomit
• can be resistant to GA

Question 24

What drug to recoveirng alcoholics use and what problems does it pose

Answer 24

disulfiram
psychotic reaction seen with those who use this drug and metronidazole

Question 25

What are the oral effects of alcohol abuse

Answer 25

• advanced caries
• risk of leukoplakia and OC
• glossitis
• angular stomatitis
• RAS
• sialosis
• rhinophyma
• erosion
• nocturnal brusism
• xerostomia - dehydration

Question 26

What are the systemic manifestations of alcohol abuse

Answer 26

• liver cirrhosis - drug metabolism and bleeding risk
• bone marrow suppression: anaemia and thrombocytopenia
• impaired wound healing: immunosuppression
• avoid use of aspirin and NSAIDs due to gastric erosion
• paracetamol safest
• avoid metronidazole as inhibits breakdown of acetylaldehyde

Question 27

What are opiates

Answer 27

morphine
methadone
dihydrocodeine
heroin

Question 28

What are the effects of opiates

Answer 28

• euphoria
• followed by sedative state
• dependant px may find analgesia ineffective in controlling dental pain
• never prescribe opiates to this group

Question 29

What are the dental implications of opiate abusers

Answer 29

• trauma
• infective endocarditis
• oral neglect
• drug metabolism

Question 30

Why does methodone pose risk to oral health

Answer 30

• often used long term
• contains high sugar content

Question 31

What is dental advise for methodone users

Answer 31

• use a straw
• drink water after consumption to prevent regurgiation
• dont brush teeth immediately after
• engage with dental services
• prevention
• sugar free suspensions available however pose greater risks

Question 32

What are the risks of cannabis use

Answer 32

• oral cancer
• psychosis including schizophrenia
• impaired memory
• impared cognitive function
• xerostomia
• caries

Question 33

What are the dental implications of cocaine

Answer 33

• may present with unusual ulceration on gingiva
• NCTSL
• orofacial pain
• long term –> palatal adn nasal septum perforation
• interaction with LA - delay tx ideally 24h after administration (increased BP)

Question 34

What is practical advise for tx drug abusers

Answer 34

• dont use adrenaline containing for px taking cocaine, ecstasy and methamphetamines - risk of increasing BP
• avoid adrenaline containing LA for cannabis user due to prolonged tachycardia risk
• alcohol abusers –> liaise with GP prior to invasive tx . may want some tests

Question 35

What are some negative side effects of opiods?

Answer 35

-nausea
-respiratory depression
-tolerance/addiction
-infective endocarditis risk