Substance abuse 2- Dental Implications Flashcards
What is the role of the GDP when treating patients who suffer from substance abuse?
Recognise in patients/colleagues
Emergency treatment
Signpost to addiction services
-> referral to hospital
Maintain dental health during rehab
Provide comprehensive judgement feee dental care
Empathy for behaviour
Realistic treatment planning
What are the causes of substance abuse?
Social deprivation
Poor housing
Adverse childhood experiences
Poor role models
Low educational aspiration
Lack of opportunities
Barriers to advancement
High unemployment
How can we recognise substance abuse?
Loss of reliability
Mood and behaviour changes – present defensively, angry or challenging
Impaired ability to drive
Subjective symptoms with no objective evidence
Requesting specific drugs
Progressive deterioration in personal appearance and hygiene
Tremors
Constricted or dilated pupils
Puncture marks, scars or pigmentation over veins
What are the barriers for people with substance abuse issues accessing dental services?
Professionals’ negative perception of these people- fear of judgement or prejudice
Pathways are not established for access
Low priority of oral health compared with drug use
Fear of dentists including needle phobia
Self-medication
Chaotic lifestyles.
Poor attendance and compliance
Cost: frequent changes in or loss of employment
Behaviour
What are the facilitators to access for dental care in people with substance abuse issues?
Housing
Education
Counselling
Support networks
BBV vaccinations
Life skills
Parenting skills
Pregnancy support
What can help people with homelessness and substance abuse issues access dental care?
Mobile dental units
Why is it important to take a thorough history in patients with substance abuse issues?
Assessing risk and patient motivation
What questions should we ask patients who we suspect may abuse substances about (sensitively)?
Alcohol consumption- number of units
Use of drugs- prescription and recreational
-> quantity
Smoking status
Living arrangements
What are the medical implications of substance misuse?
General/Oral health neglect
Increased risk of infection- TB, BBV, STI
Chronic liver disease- impaired drug metabolism and bleeding risk
IE
Venous thrombosis
What are patients with substance abuse issues more at risk of in terms of social history?
Assaults , theft, prostitution
Maxillofacial injuries
Sharing of needles- BBV
Family disruption
Change in address (or no address)
Prison
Attempted rehab
Chaotic lifestyle
What should be done if a patient is abusing substances and needs to consent to treatment?
Many drug users have fluctuating capacity
-> postpone treatment if you suspect them to be under influence
What are some examples of alcohol related brain damage?
Wernicke’s encephalopathy
Korsakoff’s syndrome
What should be done when treatment planning for patient with substance abuse issues?
Assess patient expectations and be realistic
Flexible approach- patient may present with unexpected symptoms requiring additional tx
Initial stabilisation- remove active caries/extripate as required and place temporaries
All management should include
-> Diet and OHI
-> Enhanced prevention- F toothpaste, FV, mouthwash, tooth mouse, gum
Keep treatment simple during substance misuse- ART/SDF
What are the effects of LA in patients who abuse different substances?
LA resistance- opioid users/anxiety disorders
Cannabis- ADR can prolong acute tachycardia (avoid)
Alcohol
-> LA metabolised in liver, keep doses to a minimum (2 can trigger CNS toxicity in severe liver disease)
-> Avoid IDB if coagulation issue
What else must dentist be careful with when giving LA to patients with substance abuse issues?
Pain described by patient should be consistent with clinical findings
-> if not patient may be motivated to receive treatment to feel effects of anaesthetic
What are the effects of substance abuse issues on sedation?
IS is safest
Patients may have developed tolerance to IV sedation
-> require large doses
Alcohol and opiods are synergistic with sedatices- so avoid IV in these cases
GA and IV sedation can trigger relapse
Venous access can be difficult due to collapsed veins
What is the issue with patients taking disulfiram for alcohol addiction when receiving sedation for dental tx?
Inhibits metabolism of benzos
-> increases sedative effect
What are the risk factors for necrotising periodontal disease in people with substance abuse issues?
HIV
Malnourishment
Extreme living conditions
Smokers
Stress
What are the signs and symptoms of necrotising perio diseases?
Pain
Ulceration of papillae
-> loss?
Grey necrotic tissue
Halitosis
Lymphadenopathy- tender and palpable
Why is oral cancer more common in patient with substance misuse issues?
smoking
alcohol
direct application of drug to the oral mucosa
poor nutritional and immune status
socio-economic status
How are patients with alcohol misuse managed?
Morning appointments- less likely to be under influence
Aim to help with other issues like smoking
Be aware of tolerance and addiction to sedation
Avoid GA- increased risk of vomiting, resistance
Avoid metronidazole if on disulfiram- psychotic reaction
Be mindful of consent
Liver cirrhosis- drug metabolism and bleeding risk
Avoid NSAIDs
Impaired wound healing- immunosupression
What are the oral implications of alcoholism?
Advanced caries
Perio
Increased risk of leukoplakia and cancer
Angular stomatitis
RAS
Sialosis
Rhinomphyma
Erosion- acidic beverages, gastric reflux and vomiting
Bruxism
Dry mouth- dehydration and vomiting
What are examples of opiates a patient may be on?
Heroin
Methadone
Morphine
Dihyrdocodeine
What are the dental implications of opioid addicts?
Risk of trauma
IE
Enhances sedation
Oral neglect
Impaired drug metabolism
Issues with LA
Requesting opiate drugs for pain- only indicated in dentistry for sever post-op pain
What is methadone?
Thick green syrup with high sugar content
-> 2.5mg of sugar per 5ml
-> Higher caries rate- encourage sugar free
What dental advice is given to methadone users?
Use a straw to take it
Drink water afterwards- prevent regurgitation
Don’t brush teeth immediately after
Engage with dental services
Enhanced prevention
Sugar free suspension
What are the main forms of cannabis?
Marijuana (smoked)
Hashish
Hash oil
What are the dental implications to consider for patients on cannabis?
Increased risk of oral cancer
Psychosis- schizophrenia
Consent issues- impaired memory and cognition
Xerostomia- caries
What are the effects of cocaine?
Initial effects- euphoria and mental clarity
Large doses- hallucinations and paranoia
How may cocaine use present to dentist?
Unusual ulceration on gingivae
NCTSL
Caries
Oro-facila pain
Palatal and nasal septum perforation- acidic and cause vasoconstriction
What is the issue with cocaine use and LA?
It interacts with LA
-> delay treatment for 6-24 hours after administration
-> avoid systemic increase in BP (same for ecstasy and methamphetimines)
What tests may be done prior to commencing treatment on a patient with alcoholism?
FBC
Coagulation screening
LFT
-> to determine risk of bleeding and need for onward referral
