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Alcohol and Drug Abusers Disease/Medical Condition SUBSTANCE USE DISORDER Date of Publication: June 20, 2019 (also known as “SUD”, “drug use disorder”, and “substance-related disorder”1; includes “drug or alcohol dependency” [also known as “drug addiction or alcoholism”, “chemical dependence”, and “chemical dependency”] and “drug or alcohol abuse” [also known as “substance abuse”]) Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No, unless: ― the patient/client displays behavioural signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., extreme restlessness or aggression); or ― the patient/client is intoxicated or “high” and therefore is incapable of giving informed consent. Is medical consult advised? — Yes, if undiagnosed substance use disorder (abuse or dependence) is suspected. The patient/client’s primary physician may be able to assist with access to a treatment program or an addiction treatment specialist. ― Yes, if poor response to substance abuse/dependence treatment is suspected.2 Is the initiation of invasive dental hygiene procedures contra-indicated?** Yes, if drug or alcohol dependency is of a type or extent that may affect the appropriateness or safety of scaling and root planing, including curetting surrounding tissue (as per Ontario Regulation 501/107). Is medical consult advised? ...................................... See above. Additionally, before aggressive nonsurgical (or surgical) periodontal therapy is undertaken, the patient/client’s physician should be consulted to confirm there is no immunosuppression or significant liver or kidney damage. Also, pain control should be coordinated with the primary care physician for patients/clients recovering from substance abuse/dependence. Is medical clearance required? — Yes, if drug or alcohol dependency meets the proscribed initiation criteria of O. Reg. 510/107. — Yes, if the patient/client has history of intravenous (IV) drug abuse. — Yes, if there is a bleeding disorder (e.g., caused by thrombocytopenia resulting from alcoholism or habitual cocaine use). Is antibiotic prophylaxis required? ............................. Possibly, if the patient/client has a history of intravenous drug abuse.3 Is postponing treatment advised? — Yes, in most circumstances where the patient/client has “self-medicated” with drugs of abuse or alcohol prior to the dental/dental hygiene appointment. If the patient/client is “high” or intoxicated, procedures should be deferred until the patient/client is not mentally impaired and not at undue risk of significant myocardial ischemia, cardiac arrhythmia, or other serious medical sequelae in the operatory (particularly with use of cocaine or methamphetamine). Patients/clients “high” on methamphetamine should not receive dental treatment for at least 8 hours (and ideally at least 24 hours) after last administration of the drug. ― Yes, if patient/client is medically unstable. An overdose of an abused substance requires immediate medical attention. Alcohol poisoning is a medical emergency. ― Yes, if the patient/client has untreated alcoholic liver disease. Elective, outpatient dental/dental hygiene care should be deferred pending assessment by a physician regarding bleeding risk, etc. ― Yes, until medical assessment has occurred regarding possible antibiotic prophylaxis in patients/clients with history of intravenous drug abuse. — Yes, if the patient/client is unwilling or unable to comply with treatment. When recovery from addiction is further progressed, the patient/client may be more receptive to dental hygiene care. 1 “Substance-related disorder” also encompasses “substance-induced disorders” including intoxication, withdrawal, and other substance/ medication-induced mental disorders. These conditions are also addressed to some degree in this fact sheet. 2 Behavioural and pharmacologic treatments are used to treat drug or alcohol addiction. Medications used to treat depression and anxiety disorders are also used to treat patients/clients with addictive behaviour disorders. For alcoholism, alcohol sensitizing agents (e.g., disulfiram and citrated calcium carbamide), anti-craving agents (such as naltrexone), and antiemetic agents (such as ondansetron) may be employed. For patients/clients with addiction to heroin or narcotic painkillers, methadone (an opioid agonist) or buprenorphine (a partial opioid agonist/antagonist) can be used. Naloxone is an opioid antagonist used to block or reverse the effects of opioids, particularly for opioid overdoses. 3 Many IV drug users develop venous thrombosis and organic valvular heart disease. In particular, damage to the tricuspid valve is often associated with IV substance abuse. As well, IV drug use can result in endocarditis caused by Staphylococcus aureus on nonsterile needles. cont’d on next page... Disease/Medical Condition SUBSTANCE USE DISORDER (also known as “SUD”, “drug use disorder”, and “substance-related disorder”; includes “drug or alcohol dependency” [also known as “drug addiction or alcoholism”, “chemical dependence”, and “chemical dependency”] and “drug or alcohol abuse” [also known as “substance abuse”]) Oral management implications Patients/clients who are dependent on alcohol or drugs or who are receiving treatment for substance abuse pose complex issues for the dental hygienist related to preventive oral healthcare. In addition to poor self-care, there are numerous potential oral manifestations of substance abuse. History-taking should include explicit questions about “recreational drugs” and “alcohol”, in addition to “prescribed medications”, “drugs”, and “over-the-counter medications”. Chemically dependent patients/clients should be identified to avoid interactions between drugs used in the dental office and abused substances. Patients/clients with substance abuse issues typically seek dental care only when they are in severe pain. Furthermore, the oral health problem is often in an advanced state, because of neglect or because pain sensation has been blunted by the use of drugs. Chemically dependent patients/clients may also experience tolerance to analgesics and sedatives. Red flags for suspicion of substance abuse in a patient/client include: frequently misses appointments; careless appearance and poor hygiene; lapses in concentration and/or memory; smell of substance on breath, body, or clothes; slurred speech; rapid mood swings; needle marks on arms; abnormal pupillary constriction or dilatation; wears sunglasses in operatory (to cover dilated or red pupils, red eyes, or blank stare); wears long clothes on a hot day (to cover needle marks); continually sniffs nose and uses tissues; hacking cough; tremors of hands or head; frequently requests specific medication for pain; and high tolerance to analgesics and sedatives. The dental hygienist should determine if the patient/client has “self-medicated” with alcohol or drugs prior to the dental/ dental hygiene appointment. If so, then the care plan may need to be modified or cancelled to avoid any substance- associated behavioural problems, drug interactions (e.g., with local anaesthetics or nitrous oxide), or other safety issues. Drugs that depress brain activity ― such as opioids, benzodiazepines, and antihistamines ― can enhance the effects of local anaesthetics. Because some drug-abusing patients/clients may seek dental/dental hygiene treatment to obtain prescriptions for abused substances, prescription pads should be kept out of sight and be inaccessible. Multiple short appointments may be necessary to manage anxiety or emotional instability in drug-dependent patients/clients. Blood pressure and pulse should be monitored during appointments for cocaine and methamphetamine abusers. Such patients/clients are at elevated risk for cardiac arrhythmias, myocardial infarction, and stroke. Malnutrition is common in substance abusers, and thus nutritional counselling and dietitian referral may be indicated. Methamphetamine users tend to consume large amounts of soft drinks, which compounds the problems of “meth mouth”. The remaining dentition is often unsalvageable, with extractions being the only viable option. Patients/clients who are in recovery programs may seek long-neglected oral healthcare as part of their recuperation efforts. However, recovering addicts may be very reluctant about taking any type of medication, thus complicating efforts to control pain during scaling and root debriding. Pain control should be coordinated with the primary physician. If a chemically dependent patient/client requires sedation with nitrous oxide or benzodiazepines for dental treatment, he/ she should be referred to practitioners experienced in treating such patients/clients. Persons with a significant substance abuse history and needing extensive dental treatment may require care in a hospital or operating room. Opioid analgesics and other addictive substances should be avoided if possible in patients/clients with drug/alcohol abuse or dependence. If prescribed, the patient/client should be monitored to ensure proper medication use. A “pain contract” outlining specific pain management strategies may be indicated, and engagement of the patient/client’s primary physician in this process should be considered. In most circumstances, nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for post-procedure pain to avoid addiction issues posed by opioids. Epinephrine should be avoided for 24 hours after the last use of cocaine or methamphetamine. Excessive bleeding
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