Substance Abuse: Systemic and Oral Manifestations (Part 1)

EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants.

Substance abuse: Systemic and oral manifestations (Part 1)

A peer-reviewed publication Written by Kandice Swarthout, MS, RDH, LPC, NCC

PUBLICATION DATE: JANUARY 2019

EXPIRATION DATE: DECEMBER 2021

SUPPLEMENT TO PENNWELL PUBLICATIONS EARN

This educational activity was developed by PennWell’s 3 CE dental group with no commercial support. This course was written for dentists, dental CREDITS hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self- instructional journal and web activity. Provider disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity, nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Substance abuse: Systemic and Requirements for successful completion: To obtain three (3) CE credits for this educational activity, oral manifestations (Part 1) you must pay the required fee, review the material, complete the course evaluation, and obtain a score of at least 70%. EDUCATIONAL OBJECTIVES CE planner disclosure: Laura Winfield, CE At the conclusion of this educational activity, participants will be able to: coordinator, does not have a leadership or commercial interest with products or services discussed in this 1. Know a variety of drugs that may be used by patients. educational activity. Ms. Winfield may be reached at 2. Learn the oral effects of a variety of commonly used drugs. [email protected]. 3. Learn the systemic effects of a variety of commonly used drugs. Educational disclaimer: Completing a single continuing education course does not provide enough 4. Understand drug’s pathway to the brain and the long-term ramifications. information to result in the participant being an 5. Know the importance of routine oral cancer screenings for patients that use expert in the field related to the course topic. It is the combination of many educational courses and clinical defined substances. experience that allows the participant to develop skills and expertise. ABSTRACT Image authenticity statement: The images in this educational activity have not been altered. Drugs and alcohol contribute to the death of approximately 90,000 Americans Scientific integrity statement: Information shared annually. With the use of marijuana, alcohol, and other drugs on the rise, den- in this CE course is developed from clinical research tal professionals are at the front lines of recognizing addiction and the oral and and represents the most current information available from evidence-based dentistry. systemic effects on patients. When clinicians are trained to recognize mani- Known benefits and limitations of the data: festations of substance abuse, patient care is improved. Patients have a higher The information presented in this educational activity chance of being referred for professional mental health intervention, and there is derived from the data and information contained in reference section. The research data is extensive is an increased likelihood for early detection of drug-related oral cancers. and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for three (3) CE credits. Cancellation/refund policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Go green! Go online to take your course. www.DentalAcademyofCE.com PennWell designates this activity for three (3) continuing educational credits. QUICK ACCESS CODE 15328 Dental Board of California: Provider 4527, course registration number CA# 03-4527-15328. “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” PennWell Corporation is designated as an approved PACE program provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for fellowship, mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 11/1/2015 to 10/31/2019. Provider ID# 320452. DENTAL ACADEMY OF CONTINUING EDUCATION

INTRODUCTION As the use of legal and illegal substances climbs in America, dental professionals are challenged to recognize ill effects orally, sys- temically, and behaviorally in order to provide a high standard of care to every patient. Most dental clinicians are trained to recognize drug-seeking individuals, but may not FIGURE 1: Dental neglect due to alcoholism. Photo be equipped to offer help to those embar- courtesy Dr. Terry Rees, Texas A&M School of Dentistry rassed by years of being in the “vicious cycle” of dental fear. The vicious cycle is defined or a mixed drink containing one ounce of as the postponement of dental care until hard liquor.3 pain is the primary motivating factor. The A sedative hypnotic, alcohol comes in FIGURE 2: Candidiasis in labial commissures due patient will seek palliative treatment and many forms and is easily accessible. Etha- to alcohol abuse. Photo courtesy Dr. Terry Rees, Texas enter back into the cycle of oral neglect until nol, the form of alcohol used to make bever- A&M School of Dentistry pain arises again. This creates embarrass- ages, is very quickly absorbed into the body ment and anxiety for the patient and frus- through the stomach and small intestine. findings of high levels of Streptococcus angi- tration for clinicians.1 Especially if an individual does not consume nosus in alcohol users, increase oral cancer A drug is defined as a chemical that adequate food prior to drinking an ethanol risks significantly.5 Though alcohol stands changes body functions or mental state beverage, the molecule readily gains access alone as an independent risk factor for oral and works by attaching to molecular recep- to every cell in the body. Whether consumed cancer, combining tobacco has a synergis- tor sites. The drug binds to the receptor to as beer, wine, spirits, or whiskey, the initial tic effect by decreasing the levels of immu- activate it and becomes an “agonist.” If a “buzz” of alcohol is felt as relaxation for the noglobulin-A and remarkably increases a drug binds to a receptor and does not acti- first 30 minutes and shifts into sedation as patient’s risk for oral cancer.6 In the 2009 vate it, but blocks it from other molecules, it is eliminated from the body. Most peo- International Head and Neck Cancer Epide- it becomes an “antagonist.” The quantity of a ple who consume alcohol chase the feel- miology consortium, researchers measured drug is dependent upon how tight it binds to ings experienced in the first 30 minutes by oral cancer risks of using alcohol or tobacco the receptor site and efficacy is determined drinking more, but can never reach that goal alone verses using the drugs combined with by how well the drug alters receptor func- as the sedative effect takes place. Unfortu- a metric called the Population Attributable tion. Some drugs may require less dosing to nately, this results in excessive use, unwanted Risk (PAR). They found that the combina- achieve the desired outcome.2 behavior, and sleepiness.2 tion of tobacco and alcohol use is “multipli- No matter the amount taken or exact The majority of ethanol is metabolized by cative” for oral cancer risk.7 mechanism of action, the body and brain the liver, where an enzyme called dehydro- Oral manifestations of alcohol abuse are must adjust and accommodate function and genase (ADH) breaks it down into acetalde- as follows: xerostomia, buccal cervical car- mental changes. These adjustments often hyde, a highly toxic molecule.4 Acetaldehyde ies, poor oral hygiene, broken teeth due to manifest as oral side effects that are noticed is further broken down into acetate which, in accidents related to intoxication, gingival by dental hygienists during patient care. This turn, becomes part of the energy sequence bleeding upon probing, erosion related to two-part course will begin by addressing of the cell. When alcohol is consumed too vomiting, coated tongue, attrition related the systemic and oral effects of substances. quickly, the interim product of acetaldehyde to bruxism, candidiasis in labial commis- Part 2 covers the realities of addiction, social causes a person to feel sick until it all can be sures, and glossitis due to nutritional defi- stigmas, and effective patient management. further broken down into acetate. The liver ciency.8 These conditions challenge a skilled can metabolize the equivalent of approxi- clinician to ensure oral cancer exams are DRUGS OF CHOICE mately one ounce of whiskey an hour.2 being performed at each dental visit. AW Alcohol The metabolism of alcohol is impor- van Zyl (2014) states, “Alcohol being such an The 2016 National Survey on Drug Use and tant for dental professionals to understand important risk factor for oral cancer is often Health reported that 136.7 million Ameri- because the oral tissues are the first to be overlooked by oral health-care clinicians cans over the age of 12 currently use alcohol. exposed when beverages are initially con- and the public remains largely ignorant Of those 136.7 million, 65.3 million admit to sumed. One study that describes acetalde- of this fact.” This statement solidifies the being binge alcohol users and 16.3 million hyde as a carcinogen reports that the initial importance of oral cancer screening by are heavy users. Binge alcohol use is defined contact of alcohol to the oral mucosa dis- dental professionals at routine intervals, as five or more standard drinks for men and rupts lipid membranes, allowing the carcin- especially when alcohol abuse is suspected.9 four or more standard drinks for women on ogens to penetrate the epithelial squamous In addition to the common oral hygiene an occasion. Standard drinks are described cells. The combination of the membrane instructions hygienists recommend for as one 12-ounce beer, one four-ounce wine, disruption, increased xerostomia, and the patients with the above conditions, a study

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has shown that rinsing with an antiseptic and 6% use it on a daily basis.12 correlated for increased infection as mari- mouthwash reduces the salivary acetalde- Marijuana most commonly enters the juana lowers anti-tumor activity.9 Chronic hyde by 30% to 50% after the consumption bloodstream through smoking, but many marijuana smokers exhibit an 11-fold of alcohol.10 With thorough screenings, effec- people consume it by way of edibles. Smok- increase in the chances of HPV-16 positive tive communication, and proper oral hygiene ing provides a more rapid high while eating head and neck squamous cell carcinoma instruction the alcoholic patient can experi- marijuana takes longer to enter the blood- compared to those who use infrequently.14 ence a reduced-stress dental appointment stream and offers an extended sense of As cannabis becomes less taboo in soci- and return for preventive care which may, euphoria. Marijuana increases dopamine ety due to legalization and beliefs about its in turn, increase the chances for early dis- in the brain by acting on GABA nerve ter- benefits, more dental patients will display ease detection. minals and binds on the same receptors as the above oral manifestations. Dental profes- endocannabinoids, which are endogenous sionals may find patient management with Marijuana to the human brain. These receptors are those who use marijuana a challenge as they Marijuana has many slang or street names, found on presynaptic CB1 receptors that may present as anxious and/or paranoid. including pot, weed, herb, reefer, grass, and are more abundant in the developing brain Administration of epinephrine-containing ganja.2 Derived from the cannabis plant, than the adult brain.13 local anesthetics may also pose a problem marijuana is categorized as a Schedule I Residual effects of marijuana can hinder due to prolonged tachycardia triggered by narcotic by the Drug Enforcement Agency cognitive function up to 48 hours after use. cannabis use.5 With these issues surrounding (DEA), meaning it has no valid clinical use Chronic users that use everyday or every marijuana use and oral health, it is essential and high potential for abuse, even though it other day may never get a reprieve from that dental professionals remain up-to- date is used for medicinal purposes in designated lingering impairment.2 More research is on signs and symptoms and remain diligent states.11 Laws regarding possession and use required to fully understand the long-term in the early detection of oral cancer. vary from state to state. The main psychoac- effects of persistent marijuana use. tive ingredient in marijuana is THC (delta-9 It is still uncertain as to whether mari- Ecstasy tetrahydrocannabinol), and it is classified by juana is a risk factor in oral cancer, but it is A Schedule I drug in the class entactogens, grade based on the level of THC, with “low- still imperative for dental professionals to Ecstasy has a high potential for abuse. Street grade” marijuana being the lowest and hash view marijuana as a prospective promoter names include rolls, beans, molly, X, XTC, oil being the highest.2 The National Institute to oral cancer. A 32-year longitudinal study Adam, Eve, and love. The psychoactive drug on Drug Abuse reports that marijuana is the revealed that marijuana smoking increases in Ecstasy is methylenedioxymethamphet- most commonly used illicit drug and more the rampancy of periodontal disease seven amine (MDMA), but it is common for deal- than 22 million Americans reported using it times that of non-users.9 Other clinical signs ers to sell pills that contain fillers such as in the last month.20 Use amongst teens has of marijuana use include gingival enlarge- ephedrine and ketamine as a substitute. A reportedly gone down in the last decade, but ment, stomatitis with leukoedema, xerosto- survey showed that 60% of the pills submit- remains highest with seniors in high school. mia, and Candida albicans.9 ted for testing contained little or no MDMA. In a survey, 26% of 12th graders reported in Marijuana use and Human Papilloma This is risky for users as they do not know a survey to using marijuana in the last year Virus-16 (HPV-16) are strongly positively exactly what they are purchasing.2 MDMA is used primarily at dance parties called “raves” by teens and young adults. It is well-absorbed by the digestive system, and its levels peak around one hour after use and last for three to six hours.2 As the drug peaks, a massive release of serotonin is experienced, leading to intense feelings of euphoria, empathy, elevated sensory per- ception, and a sense of closeness to others.15 Oral manifestations have been recognized as side effects from Ecstasy use. Severe xerostomia has been reported to last up to 48 hours after taking the drug. While under the influence of Ecstasy, a majority of users consume an excessive amount of soft drinks to prevent dry mouth, hyperthermia, and dehy- dration caused by elevated body tempera- ture. This increases the risk of dental caries FIGURE 3: Marijuana induced gingival enlargement. Photo courtesy Dr. Terry Rees, Texas A&M School of Dentistry. and erosion.15 A study of 428 Ecstasy users

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revealed bruxism in 40% of the sample after 24 hours and 28.6% after 48 hours of taking TABLE 1 REFERENCE: DIAGNOSTIC AND STATISTICAL MANUAL FOR the drug.9 Another study showed majority MENTAL DISORDERS-5.25 of wear on the lower first molars, which is The DSM-5 lists the following criteria for cannabis use disorder: indicative of clenching rather than grinding. 1. Use of cannabis for at least a one-year period, with the presence of at least two of This can ultimately result in TMJ dysfunc- the following symptoms, accompanied by significant impairment of functioning tion. Oral mucosa is sometimes affected and distress; by Ecstasy. Out of 466 study subjects, 8.2% 2. Difficulty containing use of cannabis. The drug is used in larger amounts and over reported mouth ulcers 24–48 hours after a longer period than intended; use.15 Whether these signs and symptoms are 3. Repeated failed efforts to discontinue or reduce the amount of cannabis that is seen individually or comorbidly, it is impor- used; tant for dental professionals to be aware 4. An inordinate amount of time spent acquiring, using, or recovering from the effects of potential causes. Intervention may not of cannabis; only intercept the progression of serious 5. Cravings or desires to use cannabis. This can include intrusive thoughts and images oral health issues, but also allow dental cli- or dreams about cannabis, or olfactory perceptions of the smell of cannabis due to nicians to provide education about the dan- preoccupation with it; gers of MDMA use. 6. Continued use of cannabis despite adverse consequences from its use, such as criminal charges, ultimatums of abandonment from spouse/partner/friends, and Methamphetamines poor productivity; Methamphetamine (mAMPH), also known 7. Important activities in life, such as work, school, hygiene, and responsibility to fam- as meth, ice, crystal, and crystal meth, is ily and friends, superseded by the desire to use cannabis; a highly addictive stimulant made from 8. Cannabis used in contexts that are potentially dangerous, such as operating a pseudoephedrine, an ingredient in over- motor vehicle; the-counter decongestants. In the form of 9. Use of cannabis continues despite awareness of physical or psychological problems powder, rocks, capsules, or tablets, meth- attributed to use, e.g., anergia, amotivation, and chronic cough; amphetamine can be smoked, swallowed, 10. Tolerance to cannabis, as defined by progressively larger amounts of cannabis snorted, or injected.2 In the United States, needed to obtain the psychoactive effect experienced when use first commenced, it is estimated that 12 million people over or, noticeably reduced effect of use of the same amount of cannabis; the age of 12 have used methamphetamine; 11. Withdrawal, defined as the typical withdrawal syndrome associated with can- 1.2 million people admit using it in the last nabis. Cannabis or a similar substance is used to prevent withdrawal symptoms. year and 440,000 people admit using it in the last month. In 2012, 535,000 individuals were estimated to meet the criteria in with the common term “meth mouth” and inflammation, trismus, candidiasis, glossitis, the Diagnostic and Statistical Manual of may have seen at least one methamphet- and myofacial pain.19 Mental Disorders-IV for stimulant abuse amine abuser in clinical practice. Meth In addition to providing proper biofilm and dependence.16 mouth is a severe and rampant form of tooth control instructions, nutritional counseling, Meth rapidly enters the bloodstream decay that usually begins on the buccal sur- and fluoride recommendations, dental clini- and the high can last for two to four hours faces9 and is controversial and inconclu- cians should be especially aware of the del- depending on the avenue of consumption. sive as to whether the actual cause of the icate balance between methamphetamine Marshall and O’Dell (2012) state that “on decay is from contact with the teeth dur- use and dental anesthesia administration.19 intake ‘methamphetamine’ leads to eupho- ing smoking, poor oral hygiene due to self- Local anesthetics with vasoconstrictors ria, increased vigilance, hyperactivity, and neglect, reduced buffering capacity of meth should be used with caution. Dispensation cardiovascular changes. However, when users resulting in lower pH of the saliva,9 of vasoconstrictors may result in myocardial taken repeatedly or in higher doses, mAMPH reported higher than normal consumption infarction, cardiac dysrhythmias, and cere- can result in adverse physiological and neu- of sodas due to xerostomia,2 or a combined brovascular accidents. Dentists and hygien- rological consequences, including weight variation.18 One study found that intravenous ists need to be particularly well-informed of loss, muscular wasting, periodontal necro- users had more drug use-associated tooth the patient’s health history, drug-use hab- sis, brain injury, and impaired memory and loss than smokers of mAMPH. The question its, and clinical manifestations that exhibit executive functions.” mAMPH can remain in remains whether this is due to the toxicity of methamphetamine abuse prior to prescrib- the body for up to a day after a single dose. the drug itself or other correlated factors.18 ing anesthesia.20 This lingering effect is believed to cause the The American Dental Association warns long-term cognitive dysfunctions and brain that methamphetamine abuse can be asso- Opioids injury often seen in abusers.17 ciated with several other oral issues, such as Opioids are classified by the DEA varying Most dental professionals are familiar bruxism, TMD, xerostomia-induced gingival from Schedule I to Schedule IV, depending

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upon risk of abuse and medical use. Opioids the doctor investigating the patient’s opi- for the appropriate intervention is crucial in include heroin, codeine, morphine, fentanyl, oid prescription history, limiting the supply providing quality care and potentially sav- and prescription pain medications such as prescribed, and not allowing refills without ing patients’ lives. In addition to clinically hydrocodone and oxycodone.12 Because a new prescription.22 detecting manifestations of drug use, effec- dentistry has been under scrutiny for over- It is important that dental professionals tive communication and empathy are key prescribing prescription opioids, this section are educated on respective state laws and components to guiding patients to proper will focus on commonly prescribed opioids work diligently to ensure that over-prescrib- life-changing interventions. These compo- for dental pain. ing is curtailed in an effort to end the opioid nents, as well as realities and stigmas of Opioids serve as effective analgesics crisis in America. addiction, will be discussed in Part 2 of this by binding to the endogenous opioid neu- course. rotransmitter receptor sites in the brain that ORAL CANCER SCREENINGS are involved in the modulation of pain. These Lastly, with the extent of oral manifestations REFERENCES receptor sites are involved in many bodily brought on by substance use discussed in 1. Swarthout-Roan K, Singhvi P. The roots of dental functions, including processing pain sensa- this paper and the many substances not fear. RDH magazine. 2013. tions and activating reward centers. When discussed, it is imperative that every dental 2. Kuhn C, Swartzwelder S, Wilson W. Buzzed: The opioids bind to the receptor site, pain is hygienist is doing an oral cancer screening on straight facts about the most used and abused blocked and dopamine is released, creat- every patient at regular intervals. Modifiable drugs from alcohol to ecstasy. Norton and ing a sense of euphoria for the user.2 When risks such as drugs and alcohol are seen in Company. New York, NY. 2014. Duke University taken in small and recommended amounts, epidemiological trends as major contribu- and Duke University School of Medicine. opioids are safe and effective for acute pain tors to oral cancer. It is important for den- 3. Substance Abuse and Mental Health Services issues.21 Contrarily, massive misuse has cre- tal clinicians to be aware of risks, clinical Administration https://www.samhsa.gov/data/ ated a nationwide epidemic, putting many manifestations, and proper interdisciplin- sites/default/files/NSDUH-FFR1-2016/NSDUH- people in life-threatening situations.22 ary action for patient care.6 FFR1-2016.htm#alcohol3. The most commonly prescribed opioids In 2017 the American Dental Associa- 4. Zakhari S. Alcohol metabolism and epigenetic for dental pain or postoperative discom- tion Council on Scientific Affairs published changes. Alcohol Research: Current Reviews. fort management are immediate release guidelines for the evaluation of oral lesions. 6-16. 2013. (IR), such as hydrocodone and oxycodone. Those guidelines include: a medical/dental/ 5. Cope G. Alcohol and recreational drug use: The Research reports that abuse of IR opioids for social update and intraoral and extraoral effects on oral health. Dental Nursing. Vol 8 no 1. non-medical use has increased significantly examination on every adult; in the presence 2012. 14-17. as it positively correlates with a rise in pre- of a lesion, the clinician should immedi- 6. Chi A, Day,T, Nevill B. Oral cavity and scribing the drugs. Twelve percent of opioid ately biopsy or refer to a specialist; saliva and oropharyngeal squamous cell carcinoma-An prescriptions in the United States are writ- light-based devices are not recommended update. Cancer Journal for Clinicians. Vol 00 ten by dentists. It is believed that dentists for evaluating lesions. In addition to these Number 00. 2015. 1-5. are contributing to the prescribing of IR opi- guidelines, a CDT code was established. Peri- 7. Hashibe M, Brennan P, Chuang S, et. al. oids that are used non-medically and lead to odic oral evaluation (D0120) and compre- Interactions between tobacco and alcohol use abuse. In a survey of West Virginia dentists, hensive oral evaluation (D0150) both include and the risk of head and neck cancer: Pooled 41% of respondents admitted to expecting an oral cancer screening. Adequate light- analysis in the international head and neck patients to have leftover drugs based on the ing, gloves, two 2x2 gauze, a dental mouth epidemiology consortium. Cancer Epidemiol number of prescribed pills versus the indi- mirror, and approximately five minutes are Biomarkers & Prevention. February 18(2). 2009. cated dose.21 This leads to use beyond what required to perform a thorough oral cancer 8. Darby M, Walsh M. Dental hygiene: Practice and is indicated, a family member intercepting screening.23 The ADA provides a step-by-step theory. Elsevier/Saunders. St. Louis, Mo. 2015. and using the drug non-medically, or the educational video on proper cancer assess- 9. Zyl AV. Substance abuse and oral health: An sale or distribution to a person to whom the ments. Clinicians interested in learning or overview. A clinical review. South African Dental medication was not prescribed. reviewing appropriate screening protocol Association. 2014. Over 600,000 Americans lost their lives can visit https://youtu.be/7mv073MJzlg.24 10. Seitz H, Becker P. Alcohol metabolism and to prescription or illicit opioid use between cancer risk. Alcohol Research and Health. 2007. 1999 and 2016. Millions of people strug- CONCLUSION Vol. 30, No. 1. Pgs 38-47. gle with loss of productivity and emo- Dental professionals are on the front lines 11. Drug Enforcement Administration, 2018. https:// tional disturbances from opioid abuse. In of health care and have an opportunity to www.dea.gov/druginfo/ds.shtml. August of 2017, President Donald Trump advocate for patients in many ways. Dental 12. National Institute on Drug Abuse. drugabuse. declared a U.S. public health opioid crisis. hygienists spend more time with patients gov. 2018. Many states have responded to this crisis than almost any other health-care provider. 13. Willimason J, Buckland H, Cunningham S. How by passing laws to curb this epidemic. Some Education on properly detecting oral con- does marijuana work in the brain? The American of the laws involve requirements such as sequences of substance abuse and referring Biology Teacher, 75;4. 2013, 299-300.

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kettlebells and is a certified Strong First kettlebell responses to curb the opioid epidemic. The 14. Gillison M, D’Souza G, Westra W. et al. Distinct instructor. She enjoys combining her counseling and risk factor profiles for human papillomavirus Journal of Law, Medicine and Ethics, 45;2017: dental hygiene skills to assist clinicians in growing type 16–positive and human papillomavirus type 460-463. professionally and personally through better 16–negative head and neck cancers. Journal 23. American Dental Association. https://www.ada. understanding of self and others. National Cancer Institute 2008; 100: 407-420. org/en/member-center/oral-health-topics/oral- 15. Brand H, Dun S, Amerongen,A. Ecstasy (MDMA) cancer, 2018. and oral health. British Dental Journal 2008; 204: 24. American Dental Association. How to check 77-81. patients for oral cancer. https://youtu. 16. Courtney K, Ray L. Methamphetamine: An be/7mv073MJzlg, 2018. update on epidemiology, pharmacology, clinical 25. Diagnostic and Statistical Manual for Mental pharmacology, and treatment literature. Drug and Disorders-5. American Psychiatric Association. Alcohol Dependence. 143(2014);11-21. 17. Marshal J, O’Dell S. Methamphetamine influences Kandice Swarthout, MS, RDH, on brain and behavior: Unsafe at any speed? LPC, NCC, is a 1997 graduate of the Texas Woman’s University Trends in Neurosciences, 2012. 35;9;536-545. dental hygiene program. After 17 18. Robbins J, Lorvick J, Lutnick A, Wenger L, Kral A. years of private practice, Kandice Self-reported oral health needs and dental- decided to further her education care seeking behavior among women who use and graduated with her master methamphetamine. Substance Use and Misuse, of science in counseling and development from Texas Woman’s University in 47:1208-1213;2012. 2013. She is a full-time faculty member at Collin 19. American Dental Association. https://www. College, where she teaches Community Dental ada.org/en/member-center/oral-health-topics/ Health and Research. She is committed to mentoring methamphetamine. 2017. students to cultivate strong dental hygienists for the 20. Hamamoto DT, Rhodus NL, Methamphetamine future of the profession. Kandice is involved with the Texas Governmental Affairs Council, where she abuse and dentistry. Oral Diseases; 2009. persists in the fight for local anesthesia. Kandice is a 21. Denisco R, Kenna G, O’Neil M, et al. Prevention of licensed professional counselor and has worked in prescription opioid abuse: The role of the dentist. private practice and local jails as a mental health Journal of the American Dental Ass’n;142(7). counselor, focusing on trauma and crisis 22. Hodge J, Wetter S, Noe S. Emerging legal intervention. In her free time, she loves training with

NOTES

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QUESTIONS

1. Drugs and alcohol contribute to 7. What factors found in alcohol users 13. Marijuana smoking increases the approximately how many deaths increase their oral cancer risk? rampant spread of periodontal dis- annually? a. Membrane disruption ease ___ times that of non-users: a. 600,000 b. Increased xerostomia a. 7 b. 1.2 million c. High levels of Streptococcus anginosus b. 3 c. 90,000 d. All of the above c. 10 d. 200,000 d. 5 8. What is one of the oral manifestations 2. When a drug binds to a receptor site of alcohol abuse? 14. Chronic marijuana smokers exhibit and activates it, it is called a(n): a. Gingival bleeding upon probing an 11-fold increase in the chance of a. Agonist b. Ulcerations head and neck squamous cell carci- b. Chemical adaptor c. Halitosis noma caused by what strain of HPV? c. Antagonist d. Tissue sloughing a. HPV-18 d. Receptor function b. HPV-16 9. As determined by the DEA, marijuana c. HPV-11 3. What is the avoidance of preventive is a schedule __ narcotic: d. HPV-33 dental appointments until pain is not a. I tolerable termed? b. II 15. What problem may be posed when a. Dental paranoia c. III administering an epinephrine- b. Dental fear d. IV containing local anesthetic to a c. Vicious cycle cannabis user? d. Nervousness 10. What percentage of 12th grade stu- a. Dental anxiety dents reported the use of marijuana b. Seizures 4. Out of the 136.7 million current alco- within the last year? c. Prolonged tachycardia hol users, how many are heavy users? a. 6% d. Prolonged bleeding a. 65.3 million b. 26% b. 9 million c. 42% 16. Due to its absorption by the digestive c. 89.4 million d. 36% system, Ecstasy levels peak around: d. 16.3 million a. 1 hour 11. Which of the following are criteria for b. 4-6 hours 5. The liver can metabolize approxi- cannabis use disorder? c. 45 minutes mately how much alcohol in an hour? a. Tolerance to cannabis d. 2.5 hours a. 1 ounce of whiskey b. Repeated failed efforts to discontinue or b. 3 beers reduce the amounts of cannabis used 17. In the class of entactogens, Ecstasy c. 2 glasses of wine c. An inordinate amount of time is occupied is a: d. 2 shots of liquor acquiring cannabis a. Schedule I drug d. All of the above b. Schedule II drug 6. Which tissues are the first to be c. Opioid exposed when alcoholic beverages are 12. Residual effects of marijuana can hin- d. Schedule III drug consumed? der cognitive function for up to ____ a. Intestinal hours after use: 18. Where is the majority of wear due to b. Oral a. 24 clenching found in Ecstasy users? c. Muscle b. 36 a. Mandibular anteriors d. Brain c. 48 b. Maxillary 2nd molars d. 72 c. Mandibular 1st molars d. Wear was not found

8 www.DentalAcademyOfCE.com ONLINE COMPLETION QUICK ACCESS CODE 15328 Use this page to review questions and answers. Then, visit www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program, select it from the Online Courses listing and complete the online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided, and upon receiving a passing grade your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed anytime in the future by returning to the site, signing in, and returning to your Archives page.

QUESTIONS

19. What percentage of Ecstasy users 23. The ADA warned that methamphet- 27. The main psychoactive drug in mari- reported mouth ulcers 24-48 hours amine abuse can be associated with: juana is: after use? a. Clenching a. Delta-9 tetrahydrocannabinol a. 4.6% b. Glossitis b. Dehydrogenase b. 8.2% c. Halitosis c. Ethanol c. 0% d. None of the above d. GABA d. 1.6% 24. What are the most commonly pre- 28. How long can xerostomia persist fol- 20. What is another name for scribed opioids for dental pain? lowing use of Ecstasy? Methamphetamine? a. Hydrocodone a. 72 hours a. Ice b. Oxycodone b. 48 hours b. Meth c. Percocet c. 8 hours c. Crystal d. Both A and B d. only while under the influence d. All of the above 25. What percentage of opioid pre- 29. How long does methamphetamine 21. What is an adverse consequence of scriptions in the U.S. are written by last in the bloodstream? repeated use of Methamphetamine? dentists? a. 2-4 hours a. Periodontal necrosis a. 33% b. 6-8 hours b. Weight gain b. 6% c. 24 hours c. Lethargy c. 14% d. 2 days d. Nausea d. 12% 30. What significant event is an attempt 22. In a patient with “meth mouth,” 26. What is considered binge drinking? to curtail the misuse of opioids? what surface of the tooth is initially a. 3+ standard drinks for men and 2+ a. 2018 AMA conference affected by rampant decay? standard drinks for women b. Doctors self-regulating prescription writing a. Buccal surface b. 7+ standard drinks for men and 5+ c. 2017 presidential declaration of the public b. Lingual surface standard drinks for women health opioid crisis c. Occlusal surface c. 5+ standard drinks for men and 4+ d. Opioid addiction support groups d. Cervical 1/3 standard drinks for women d. 8+ standard drinks for men and 6+ standard drinks for women

NOTES

www.DentalAcademyOfCE.com 9 PUBLICATION DATE: JANUARY 2019 ANSWER SHEET EXPIRATION DATE: DECEMBER 2021 Substance abuse: Systemic and oral manifestations (Part 1)

Name: Title: Specialty:

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City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you three (3) CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For questions, call (800) 633-1681. If not taking online, mail completed answer sheet to: EDUCATIONAL OBJECTIVES PennWell Corp. Attn: Dental Division 1. Know a variety of drugs that may be used by patients. 1421 S. Sheridan Rd., Tulsa, OK, 74112 2. Learn the oral effects of a variety of commonly used drugs. Or fax to: (918) 212-9037 3. Learn the systemic effects of a variety of commonly used drugs. For IMMEDIATE results, 4. Understand drug’s pathway to the brain and the long-term ramifications. go to www.DentalAcademyOfCE.com to take tests online. 5. Know the importance of routine oral cancer screenings for patients that use defined substances. QUICK ACCESS CODE 15328 Answer sheets can be faxed with credit card payment to COURSE EVALUATION (918) 212-9037. 1. Were the individual course objectives met? Payment of $59.00 is enclosed. Objective #1: Yes No Objective #2: Yes No (Checks and credit cards are accepted.)

Objective #3: Yes No Objective #4: Yes No If paying by credit card, please complete the following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will display as “PennWell.”

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 1. 16. 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 2. 17. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 3. 18. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 4. 19. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 5. 20. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 6. 21.

10. Do you feel that the references were adequate? Yes No 7. 22.

11. Would you participate in a similar program on a different topic? Yes No 8. 23. 9. 24. 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______10. 25. 11. 26. 13. Was there any subject matter you found confusing? Please describe. ______12. 27. 13. 28. 14. How long did it take you to complete this course? ______14. 29.

15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD Code 344

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORDKEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the PennWell is an ADA CERP–recognized Provider. ADA CERP is a service of the American Dental PennWell maintains records of your successful completion of any exam for a minimum of six years. survey included with the course. Please e-mail all questions to: [email protected]. Association to assist dental professionals in identifying quality providers of continuing dental Please contact our offices for a copy of your continuing education credits report. This report, which will education. ADA CERP does not approve or endorse individual courses or instructors, nor does it list all credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS imply acceptance of credit hours by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Completing a single continuing education course does not provide enough information to give Participants will receive confirmation of passing by receipt of a verification form. Verification of Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at the participant the feeling that s/he is an expert in the field related to the course topic. It is a Participation forms will be mailed within two weeks after taking an examination. www.ada.org/cotocerp/. combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST PennWell Corporation is designated as an approved PACE program provider by the Academy of All participants scoring at least 70% on the examination will receive a verification form verifying General Dentistry. The formal continuing dental education programs of this program provider are CANCELLATION/REFUND POLICY 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD accepted by the AGD for fellowship, mastership and membership maintenance credit. Approval Any participant who is not 100% satisfied with this course can request a full refund by contacting for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The PennWell in writing. Participants are urged to contact their state dental boards for continuing education requirements. current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452. PennWell is a California Provider. The California Provider number is 4527. The cost for courses IMAGE AUTHENTICITY ranges from $20.00 to $110.00. The images provided and included in this course have not been altered.

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