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The dental team's role in the care of substance abusers and addicts

‘Oral health related Quality of Life’ is a concept that is being discussed more frequently as trends in oral health and disease alter.  As individuals we all have different opinions on what quality of life actually is. What is important for one individual may not be very important to another.

The quality of life of drug addicts and substance abusers can easily be overlooked. As the use of drugs increases on a global scale, treatment of drug users will become more common-place for the dental team. Research is showing that many substance abusers ‘quality of life” is much improved as their oral health improves. Improvements in speech and eating as well as self esteem are just some of the elements documented.

The range of legal and illegal substance that are abused is growing at an alarming rate and their their clinical effects are numerous. see http://www.thedrugswheel.com . A holistic approach from all  frontline clinical staff is now encouraged including dental teams. So awareness of not only the oral manifestations of substance abuse but also the wider issues of drugs and their effects can be beneficial for the whole team and their patients. Dental staff should feel confident in approaching patients who currently use or have used drugs. Each practice should have good referral pathways to communicate about the ‘whole care’ of the patient with other care professionals; but also to refer individuals who would consider help in tackling their addiction. Practice protocols could include flow charts on managing patients who substance abuse.

 It is likely that substance abusers may have some element of psychological impairment or mental illness and many use more than one substance including alcohol. Chaotic lifestyle can hinder adherence to oral hygiene and attendance to dental appointments. Dental phobia is reported as higher and more significantly the fear of judgement or prejudice from the dental team becomes a barrier to accessing dental care.

 In order for a dental team to be able to restore the mouth of a substance abuser who is in a withdrawal programme, it is important to know how well the individual is coping with withdrawal and rehabilitation. Therefore good communication and referral pathways should exist between the dental team and the medical team offering support for withdrawal. Gaining the trust of the patient  to disclose habitual health histories is paramount if the dental team are to create and implement an effective treatment plan. Therefore if a clinician feels a patient may have an undisclosed aspect to their medical history, a different approach of counselling a patient could be considered.

Sensitive questioning on social history including living arrangements, appointment of key workers such as social workers or probation officers and any involvement in addiction programmes can demonstrate to the patient the clinicians willingness to work constructively with other key people within the patient’s support network. Enquiry in to what the patient wants to achieve and opening discussions on what fears the patient may have can demonstrate respect and elicit autonomy from the individual.

An interesting treatment model (Mollendijk) from Holland has been used successfully for 15 years. The programme is offered to severely addicted patients and all staff do have some basic psychiatric training. However there are some ideas that can be drawn upon by teams in general dental practice. For example; a set of agreements for making and attending appointments is discussed from the outset. The treatment plan is not as “elaborate” as it might be for a non substance abuser and aesthetic options are not carried out until all other work is completed to encourage the patient to attend all appointments. Their treatment plans are flexible to take into account the rehabilitation journey of the substance abuser.

Key workers and family members can be instrumental in supporting dental attendance and or even accompanying patients to appointments. They can encourage abstinence from drugs in the hours before dental treatment (where possible) and provide consent if the individual is unable to do so. They can also assist in encouraging commitment to improved oral hygiene, diet and general self care.

Preventive action should consider

Ongoing prescription of high fluoride toothpaste such as Duraphat 5000

Recommendation or prescription of alcohol free fluoride mouthwash to be used independently of tooth brushing e.g. lunchtime

Regular fluoride varnish application 

Dietary counselling

Oral hygiene instruction

A home care plan could be written down for key workers to refer to and remind/support the patient to carry out. Agreeing  short term realistic goals with the patient, and building upon these can be key to achieving a long term adherence to improved oral care.

Sedation can be considered for very anxious patients but consideration that alcohol and opioids can have a synergistic effect with sedative drugs. Venous access can also be problematic in IV drug users due to collapsed veins. The administration of LA and prescription of drugs should be considered carefully. liver damage may be present in long term substance abusers, meaning that care needs to be taken when administering local anaesthetic. Even NSAIDs and antibiotics/antimicrobials such as erythromycin, tetracyclines, miconazole and metronidazole should be avoided in cases of severe liver damage.

In addition the patient’s compos mentis status at the time of treatment should be noted. If a patient does not appear able to consent for treatment, and does not have documentation in place for someone else to consent for treatment, then treatment should not take place.

Making this clear at the treatment planning stage can avoid cancelation of appointments.

The Quality of life of a substance abuser is severely effected by their oral health. This can be improved substantially by the implementation of multidisciplinary teamwork including the care of the dental team

Author Jo Dickinson

 

Posted by Gemma

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