Dental News - Blackened, broken, decayed teeth: Understanding and treating patients with substance use disorders

Iveta Ramonaite, Dental Tribune International

Mon. 20 February 2023

save

Dr Ronni Brown is an educator, researcher and dentist who treats patients who are in vulnerable circumstances and face enormous repercussions regarding their personal lives and their health. In this interview with Dental Tribune International, she helps dental professionals to understand the impact of substance abuse on oral health, discusses how to recognise the disorder and offers advice on how to effectively and emphatically approach and treat patients with addiction. More importantly, she explains why it is of the utmost importance for dental professionals to address the stigma surrounding substance abuse.

Dr Brown, how prevalent is substance abuse in the US, and how did you become interested in researching the link between substance abuse and dentistry?
According to the 2021 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration, substance use disorders affect 43.7 million Americans aged 12 years and older, and those aged 18–25 years are most significantly affected. A substance use disorder is characterised by the misuse of alcohol and other drugs, resulting in significant physical and mental impairment and failure to meet personal and professional obligations.

My interest in understanding substance use disorders began back in 1997 when, as a relatively new dentist, I began working at a medium-security correctional facility. I still remember my very first patient on my very first day of work. His name was Tom and he was 20 years old. He came to the jail dental clinic complaining about generalised dental pain and could not specify a particular tooth or even a particular area of his mouth.

When he opened his mouth, I gasped because I saw teeth that were blackened, broken, crumbling and grossly decayed. My 20-year-old patient needed full-mouth extractions and complete dentures. Rather than asking Tom what was going on, I assumed that his decay was caused by excessive soda and candy consumption and poor oral hygiene. I also assumed that Tom was an anomaly. However, my next patient, and the patient after that, presented with similar states of decay. I was puzzled because I had never seen such an unusual pattern of decay in my previous years of practice or even in dental school, and I began to realise that what I was seeing was more than the result of a sugary diet or poor plaque control.

I began to ask my patients a series of questions, such as “What are you putting in your mouth?” and “Why do you think that you have so many cavities?”. My patients told me that they were using methamphetamine, a powerful psychostimulant, commonly abused for its ability to cause intense euphoria, bounding energy and focus. My interest in understanding why this drug caused such rampant caries led me to conduct a research project on the impact of drug use patterns on caries severity in a population of patients who used methamphetamine. The project was carried out in collaboration with the University of California, Los Angeles and the University of California San Francisco.

What is the most important lesson you learned in treating dental patients in a correctional facility?
There have been many lessons that I have learned. First, I learned that my patients are not just inmates. They are someone’s parents, sons, daughters, friends; they are teachers, nurses, restaurant workers, bus drivers, and so on. They are more than their current situation. Secondly, I learned that the burden of oral disease is extremely significant among the most vulnerable individuals in our communities, namely those impacted by homelessness, poverty, incarceration, substance use and mental health disorders. Thirdly, I understood the importance of medical, dental and behavioural health integration to develop comprehensive treatment plans across disciplines to improve health outcomes for patients. I am fortunate to work in a multidisciplinary environment where I have access to conversations and consultations with my medical and behavioural health colleagues.

“The dentist should learn to recognise medications that the patient may be taking that are often abused”

What is the link between substance abuse and oral health; that is, how badly can drug or alcohol abuse undermine a person’s oral health?
There is a significant association between substance abuse and poor oral health outcomes. Drugs undermine oral health by causing excessive release of dopamine—a neurochemical that causes euphoria but also has deleterious effects in the oral environment, including salivary gland vasoconstriction, temporomandibular joint activation and sugar cravings. The dopamine release results in xerostomia, bruxism and increases in sugar consumption, which are all risk factors for caries formation. Furthermore, during drug use, individuals are less likely to perform daily oral hygiene and seek periodic preventive dental services, further increasing their risk of developing caries and periodontal disease.

How difficult is it to recognise that a dental patient is dealing with substance abuse, and what strategies can help the clinician recognise the disorder in patients?
There are many clues that a dental patient may have a substance use disorder. The first step is to have a comprehensive health history form that includes questions about current and past history of substance use disorders and mental health challenges. The dentist should learn to recognise medications that the patient may be taking that are often abused, for example, benzodiazepines and opioids, and enquire about the reason for their use as well as the duration of use. During the physical evaluation, the dental team should look for abnormalities in blood pressure and pulse (elevated with stimulant misuse, depressed with opioid misuse) and, while the blood pressure is being taken, examine the patient’s arms for track marks from intravenous drug use or skin-pops from subcutaneous injections. During the dental examination, the dental team should look for unusual patterns of decay, such as blackened smooth surface caries from methamphetamine use or small carious lesions on the cusps of mandibular premolars and molars from opioid use. The dental team should also be aware of behavioural changes (depressed, hyperactive or anxious affects) indicative of depressant, stimulant and opioid use.

How should dental professionals communicate with and treat patients with substance use disorders?
This is probably one of the most difficult challenges that dental professionals face: how to discuss substance use with patients. Many professionals have never been trained on how to have these conversations and what questions to ask. What further complicates the conversation is our fear of offending our patients and the thought that our patients may perceive the conversation as accusatory or judgemental.

To have this conversation, we must first understand the reasons for engaging on this. There are three reasons why this conversation is important. First, as dental professionals, we took an oath to do no harm. Asking a patient about a history of current or past substance use allows us to keep the patient safe in our practice. This information permits the clinician to make critical decisions that could affect the patient’s life, such as deciding to reschedule a patient suspected to be under the influence of a controlled substance to avoid a potential adverse drug-to-drug interaction with the adrenaline in our anaesthetic syringe. The second reason to have this conversation is to do good. Having information about the patient’s substance use history allows the clinician to develop a treatment plan that considers the xerostomia, lowered salivary pH and bruxism associated with the drug itself, as well as associated behavioural challenges such as poor plaque control and consumption of sweetened food and beverages. The third reason is to be ethical and provide the patient with referrals for sobriety or recovery support.

Having these goals in mind allows the clinician to approach the conversation objectively and compassionately. Sitting and speaking to the patient at eye level can help reduce the patient’s feelings of judgement and accusation. Using people-first language (for example, a person with an alcohol use disorder rather than an alcoholic) helps the patient feel respected rather than labelled or stigmatised. Similarly, asking the patient about his or her oral health goals and expressing your desire to help him or her achieve these goals engenders trust and cooperation.

“I have learned to lean in, trust my instincts, talk less, listen more and be respectful of [the patient’s] life circumstances and challenges”

This conversation does not have to be difficult! Trust me, I have had this conversation daily with my patients over the past 26 years. I have learned to lean in, trust my instincts, talk less, listen more and be respectful of their life circumstances and challenges. As a result, my patients have shared with me aspects of their lives that I would have never known. I have had patients cry as they shared with me how they became addicted at the age of 5 or the angst and worry that their drug use has caused their families. I have also had the pleasure of high-fiving a patient who was celebrating her 30^th day of sobriety. You never quite know how these conversations will turn out. However, one thing that I do know is that asking patients about their substance use is critical to providing safe and appropriate dental care, lending a voice, letting your patients be seen and heard and building a bridge of trust for patients.

Why is it crucial that dental professionals address the stigma of substance abuse?
The stigma surrounding substance abuse is a tragedy that is unfolding in our country irrespective of age, race, sex and socio-economic status. In 2021, more than 100,000 Americans lost their lives from unintentional drug overdose. Of those lost to this disease, how much did stigma, avoidance, shame or discrimination play in these deaths? It is estimated that only 7% of individuals diagnosed with a substance use disorder in the past year receive treatment. Again, how much does stigma, avoidance, shame or discrimination affect one’s ability to obtain critical services?

As a profession, it is time that we partner with our medical and behavioural health colleagues to address this epidemic. I always remember sage advice given to me while in dental school: one of my professors told me to only do for my patient what I would want someone to do for me! I remember those wise words and feel that they are appropriate when considering our professional responsibilities in addressing substance use disorders. Instead of imagining your patient with a substance use disorder, imagine that this person is your son, daughter, husband, wife or best friend. Wouldn’t you want someone to sit them down, listen to them, care about them, refer them for help and keep them safe? Reducing the stigma associated with substance use is likely the missing link between life and death.

Is there anything you would like to add?
I am excited to be a part of the 158^th Chicago Dental Society Midwinter Meeting! On Thursday, 23 February, I will be giving two lectures, “Treating between the lines: Understanding Rx and illicit drug abuse” and “Pulp fiction or evidence-based dentistry? Transforming your practice with science”.

For course descriptions or to view my course offerings, readers can visit www.DrRonniBrown.com. My book, A State of Decay—Your Dental Guide to Understanding and Treating “Meth Mouth”, is available on Amazon.