Madison East & Jessica Parkus

DHYG 2331
November 20, 2018

Medically Compromised Patient/Substance-related Disorder

Substance-related disorders are diagnosed when use of any substance, whether recreational or
prescribed, becomes excessive and leads to significant impairment or distress. [2] About one out
of every six American young adults (between the ages of 18 and 25) battled a substance use
disorder in 2014, (NSDUH) this represents the highest percentage out of any age group at 16.3
percent. [1] Medical effects of substance abuse are numerous, including cardiovascular,
neurological, gastrointestinal, kidney, liver, respiratory and prenatal effects. Some medications
can impact oral health. For instance, a common side effect of some medications is xerostomia.
Xerostomia increases the chance of tooth decay. Chemotherapy treatment for cancer can also
affect oral health. The chemo kills cancer cells, but can also do damage to cells in the oral cavity.

The most commonly used addictive drugs, with examples, are: cannabinoids (marijuana);
opioids and morphine derivatives (codeine, opium); stimulants (cocaine, methamphetamines);
dissociative anesthetics (ketamine); depressants (sleeping pills); hallucinogens (LSD); and other
drugs such as steroids and inhalants.

There are multiple treatments available for the substance-related disorder patient. The
treatment system for substance use disorders is comprised of multiple service components,
including the following: individual and group counseling; inpatient and residential treatment;
intensive outpatient treatment; partial hospital programs; case or care management; medications;
recovery support services; 12-step fellowship and peer supports. [3]

The primary medically assisted withdrawal method for narcotic addiction is to switch the
patient to a comparable drug with milder withdrawal symptoms, and then gradually taper off the
substitute. [4] Medications are an important part of the rehab process. Methadone, Levo-Alpha-
Acetyl-Methadol, Naltrexone, Phenobarbital and Diazepam are medications used to treat
addiction. For instance, Methadone helps manage unpleasant withdrawal symptoms and drug
cravings. Naltrexone is used specifically to treat opioid and alcohol use disorders.

Drug use affects oral health through direct physiological routes such as xerostomia, an
increased urge for snacking, clenching and grinding of teeth, and chemical erosion from applying
cocaine to teeth and gums. [5] The lifestyle that often accompanies problematic drug use also
affects oral health through high sugar diets, malnutrition, poor oral hygiene, and lack of regular
professional dental care. [5] Substance-related disorders leads to an array of oral health problems
such as tooth decay, chronic gingivitis, ulcerations of the gums, periodontal disease, xerostomia
and tooth loss just to mention a few.
 Management of the substance-related disorder patient before treatment involves recognizing
the characteristics of each patient during the process of taking the patient history and the verbal
interview of the patient. During the interview, try to obtain the confidence of the patient so that
the patient may be more likely to respond to drug related questions. There is merit in informing
the patient that the questions pertaining to substance abuse have relevance to the provision of
dental treatment. [6] Close attention should be directed toward any signs the patient may have
related to drug abuse such as personal appearance, their eyes, arms (needle marks) and behavior.

Management of a substance abuse patient presents a multitude of issues during treatment.

Proper knowledge of oral health conditions pertaining to drug abuse is a must. Also pain
management, infection control, risk of relapse, behavioral disorders and medical problems
associated would be included. Periodontal disease has a high impact on substance abusers. The
main aim of treatment is to clean out bacteria from the pockets around the teeth and prevent
further destruction of bone and tissue. [7] Helping the patient feel relaxed and comfortable and
being nonjudgmental will hopefully keep the patient coming back for treatment. Patients seem to
be more relaxed in a semi-reclined position in the dental chair.

Managing the patient after treatment would involve making decisions as to the frequency of
continuing dental appointments and possibly referral to a medical doctor or treatment program.
Develop strategies to meet the individual needs of the patient as identified from the dental
hygiene diagnosis. [4] A diagnosis may reflect multiple caries related to lifestyle changes,
periodontal infections related to methamphetamine use, gingival recession related to cocaine use
and xerostomia related to methamphetamine use. Shared decision means educating the patients
about their problems and making them partners in determining the appropriate course and the
specific elements of a proposed treatment plan. [5] The recall intervals should be based on the
needs of each individual patient.

Some contraindications of a substance abuse dental patient are as follows: never treat a
patient who is under the influence of drugs; local anesthetics with vasoconstrictors are
contraindicated for patients under the influence of cocaine; use alternative medications such as
NSAIDS for pain control. Additionally, nitrous oxide and oral or intravenous sedation should be
used with caution for drug dependent patients and only if there is no other alternative.

Indications for treatment are if the patient presents with caries, malocclusion, and multiple
restorations. Also seen is periodontal disease due to poor oral hygiene, as well as ulcerated gums,
and a high calculus amount due to poor plaque control. [4]
Madison West & Jessica Parkus

References

1. "Statistics on Drug Addiction." (2018, Sept.). Retrieved from

https://americanaddictioncenters.org/rehab-guide/addiction-statistics/

2. "Substance-Related Disorders." (2018). Psychology Today, Sussex Publishers. Retrieved from

https://www.psychologytoday.com/us/conditions/substance-related-disorders

3. Chanell, Baylor. (2014, Oct. 1) "Treatments for Substance Use Disorders." SAMHSA-
Substance Abuse and Mental Health Services Administration. Retrieved from
https://www.samhsa.gov/treatment/substance-use-disorders

4. Wilkins, E.M., Wyche, C.J., & Boyd, L.D. (2017) Clinical practice of the dental hygienist.
Philadelphia, PA: Wolters Kluwer

5. Society for the Study of Addiction. (2017, March 16). Review Confirms Link Between Drug
Use and Poor Dental Health [Press release]. Retrieved from
http://addictionjournal.org/press-releases/review-confirms-link-between-drug-use-and-
poor-dental-health-

6. Solomons, YF, & Moipolai, PD. (2014). Substance abuse: Case management and dental
treatment. South African Dental Journal, 69(7), 298-315. Retrieved from
http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0011-85162014000700007

7. Nordqvist, C. (2018, January 18). Periodontitis: Treatment, home remedies, and symptoms.
Medical News Today. Retrieved from
https://www.medicalnewstoday.com/articles/242321.php