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Addiction and Dental Problems

Addiction and Dental Problems

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After years of continuous recovery from heroin addiction, Daryll had dental surgery and received prescription opioids for postsurgery pain. His addiction was reignited after several days of using the drug.
Beth, addicted to methamphetamine, developed “meth mouth,” in which several of her teeth blackened, decayed, or broke off. She also developed gum disease.
By the time Mike was in his early forties, he had lost all of his teeth. Several were knocked out during a fight while drunk, and the others were removed due to poor dental care.
These are examples of dental problems among individuals with an addiction. Dental problems are caused by poor dental hygiene such as not regularly brushing teeth or flossing; poor eating or health habits such as consuming large amounts of drinks or foods with sugar; the effects of alcohol and other drugs on dental health; and other factors. Teeth can be broken or lost due to physical altercations over drug deals, and fights or accidents when under the influence of drugs or alcohol. Being toothless, missing front teeth, having decaying teeth, gum disease, and poor dental health can impact recovering people’s self-esteem, ability to eat, and even have a negative effect on finding a job.
How Alcohol and Drugs Affect Dental Health

Alcohol
The acid reflux associated with excessive drinking can cause stomach acids to come into contact with teeth and erode them based on the high acidity content. This can lead to decay on smooth surfaces and around existing fillings.

Tobacco
Use of this drug is associated with dryness of the mouth, oral cancers such as squamous cell carcinoma, and lung and pharyngeal cancers. Smoking cigarettes, cigars, pipes, and marijuana can lead to oral cancer. Dryness and irritation to oral tissues over time causes changes so that the tissue becomes abnormal. These changes could eventually lead to cancer.
Stimulants
All amphetamines can cause dehydration, an unusually dry mouth, and cause people to grind their teeth. Meth users may also have cravings for beverages with high sugar content. Over time, amphetamine use can lead to enamel destruction and loss of tooth structure leading to brittle, decayed, and disintegrated teeth. “Meth mouth” is characterized by severe dryness, tooth decay, and periodontal disease. This often causes teeth to break, crack, and/or fall out. Teeth may become blackened, stained, and extensively decayed. A study of 571 meth users found that 96 percent had cavities, 58 percent had untreated tooth decay, and 31 percent had six or more missing teeth (Shetty et al., 2015). The longer people use this drug, the greater the likelihood of severe dental problems, especially among women and cigarette smokers (Shetty et al., 2015).

Marijuana
Use of this drug may cause cannabinoid hyperemesis, whereby vomiting is induced and over time the stomach acid wears the enamel of the teeth away and exposes the tooth structure underneath the enamel, which is known as “dentin,” a yellowish colored, softer material than enamel. Cannabis smoke acts as a carcinogen and can cause premalignant lesions in the oral mucosa (Versteeg, Slot, van der Velden, & van der Weijden, 2008). Additional cannabis-associated oral side effects are xerostomia (dry mouth), leukoplakia (white patches on mucosa), and increased prevalence and thickness of a fungus called candida albicans, also known as a Thrush infection, which usually manifests on the tongue, inner cheek, and inner lip areas.

Heroin
Prolonged heroin use can also cause teeth to become broken down and rotten. When cocaine, heroin, and/or narcotics are taken, there can be dangerous drug interactions with local anesthetics containing vasoconstrictors.

Other Medications
Diuretics, antihistamines, proton pump inhibitors, and antidepressants all can cause xerostomia or dry mouth. When this occurs, the dryness in the mouth permits the bacterial counts to elevate and over time can cause decay on and around the teeth and restorations.

Dental Hygiene, Pain, and Opioids
When patients stop taking care of their oral hygiene, caries (cavities) may develop and then teeth and gums (gingiva) can become infected. These lead to painful conditions and cause some patients to seek relief with opioids. In addition, cough syrups may contain sugar, which when taken over time, can lead to cavities and damage to teeth, especially when oral hygiene and habits are not maintained.
When patients get teeth extracted, most commonly performed under general anesthesia, they may be prescribed or request pain medication in addition to antibiotics. The first line of treatment is usually for the dental provider to write a prescription for an opioid for four to seven days postoperatively. Dentists prescribe approximately 12 percent of opioid prescriptions nationally and between 5 to 23 percent are used for nonmedical purposes (Denisco et al., 2011).
Opioid-addicted individuals are susceptible to a variety of oral diseases, not least of which are dental cavities and periodontitis. High rates of generalized dental caries, being particularly prevalent on smooth and cervical surfaces, have been widely described in opioid users (Hamamoto & Rhodus, 2008).
Opioid analgesics may be used to manage dental pain when acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDS) are not effective in reducing pain (Siegel & Cheung, 2017). When NSAIDS are prescribed following tooth removal or other oral surgery procedures, there are fewer chances for side effects such as nausea and vomiting or constipation, which is a common postoperative experience when patients use opioids.
The long-acting local anesthetic bupivacaine (Exparel) is another nonopioid medicine that can be injected directly into the active surgical site. It has a duration of up to seventy-two hours, which is sufficient time for many cases of acute pain to pass.
Limiting the usage of opioids is not only better treatment, it also helps reduce initial exposure to a substance that can contribute to addiction for some individuals (ADA, 2005). Oral health care providers need to be cognizant of how their prescription practices can affect patients’ misuse or addiction to opioids. It is imperative that providers use nationally held standards and make decisions based on best practices and evidence-based outcomes.

Addiction Providers and Dental Care
Assessment of individuals seeking help for addiction should include a review of dental hygiene habits and dental problems. Current dental problems identified can be incorporated into the treatment plan. Patients with poor dental health can be referred for evaluation and treatment with a dentist as needed. This is not only important to improve dental health, but can also affect self-esteem since patients with bad or missing teeth may feel self-conscious or reluctant to go on a job interview.
Providers can offer information and advice on dental hygiene in addition to facilitating treatment of dental problems for patients with an addiction. They can educate patients on types and causes of dental problems, and explain to patients the issues that can occur when oral health and dental hygiene are neglected. There is a possibility of systemic issues, such as bacteremia and other cardiac and related conditions that may manifest if oral health is not addressed.
Individuals with a history of addiction seeking dental care or oral surgery can be advised to talk with their dentist or oral surgeon about addiction so they can work together to make the best decision about medications to use following a procedure. They can also be advised to talk with sponsors, peers in recovery, or other trusted individuals about strategies to minimize risk of addiction after dental care or oral surgery. Remaining vigilant about the potential for addiction or readdiction following opioid use can help some individuals sustain their recovery.

About the Authors
Richard M. Celko, DMD, MBA, is chief dental officer of the University of Pittsburgh Medical Center, Insurance Division in Pittsburgh. He is a graduate of the University of Pittsburgh School of Dental Medicine. He completed his general practice dental residency at Montefiore Hospital and received his MBA from Indiana University of Pennsylvania.
Dennis C. Daley, PhD, served for fourteen years as the chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh School of Medicine. He has been with WPIC since 1986 and previously served as director of family studies and social work. He is currently involved in clinical care, teaching, and research.

References
American Dental Association (ADA). (2017). Policies and recommendations on substance use disorders. Retrieved from https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/policies-and-recommendations- on-substance-use-disorders
Denisco, R. C., Kenna, G. A., O’Neil, M. G., Kulich, R. J., Moore, P. A., Kane, W. T., . . . Katz, N. P. (2011). Prevention of prescription opioid abuse: The role of the dentist. Journal of the American Dental Association, 142(7), 800–10.
Hamamoto, D. T., & Rhodus, N. L. (2009). Methamphetamine abuse and dentistry. Oral Diseases, 15(1), 27–37.
Shetty, V., Harrell, L., Murphy, D. A., Vitero, S., Gutierrez, A,. Belin, T. R., . . . Spolsky, V. W. (2015). Dental disease patterns in methamphetamine users: Findings in a large urban sample. Journal of the American Dental Association, 146(12), 875–85.
Siegel, R., & Cheung, J. (2017). Dental schools add an urgent lesson: Think twice about prescribing opioids. Retrieved from https://www.npr.org/sections/health-shots/2017/09/08/549218604/dental-schools-add-an-urgent- lesson-think-twice-about-prescribing-opioids
Versteeg, P. A., Slot, D. E., van der Velden, U., & van der Weijden, G. A. (2008). Effect of cannabis usage on the oral environment: A review. International Journal of Dental Hygiene, 6(4), 315–20.

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