PEDIATRICDENTISTRY/Copyright © 1980 by The AmericanAcademy of Pedodontics/Vol. 2, No. 2

Dental precautionsin treating drug addicts: A hidden problem amongteens and preteens

Charles H. Rosenbaum, D.D.S., M.S.D.

Abstract pating. Therefore, addicts eat high carbohydrate snack foods (i.e., candy bars). Theft of small items high Dentists who treat teen and pre-teen age patients carbohydrate is simple and prevents the addict from probably have been in contact with drug addicts. Addicts having to use money for food that could be used for mcty seek only crisis-oriented dental care and mayattempt to gain a prescription from the dentist. The dentist should drugs. Financial considerations may cause the addict be aware of patients who have been or are presently on to choose extraction rather than restoration of a tooth. drugs and should not treat these patients while they are A tooth that is a candidate for extraction mayprovide under the influence o[ an abuseddrug. Addicts injecting a source of prescribed narcotics from an unsuspecting drugsare potential hepatitis carriers as a result of using dentist. Oral hygiene is not practiced and may not be unsterile needles. Subacutebacterial endocarditis has been known to the addict. The drug to which the patient found in addicts and has been attributed to the response is addicted may mask dental pain until the dental of the heart valves to the cutting agents used to dilute the problem is treated by extraction.t drugs. Categories of commonlyabused drugs are narcotics, amphetamines,barbiturates, halucinogens, non-barbiturate tranquilizers, solvents and inhalents. Terms Relative to Drug Abuse Health professionals should be familiar with the fol- Introduction lowing terms and definitions: 1 ) Addiction-the effects of repeated actions of a Because of the continued proliferation of drug drug until its use becomes necessary and cessa- abuse amongthe population today, dental health pro- tiou of which causes physical and/or mental dis- fessionals find themselves knowingly or unknowingly turbances. treating patients who suffer from substance abuse. A number of drug abuse problems interface directly 2) Tolerance-the need for increasing amounts of a drug to obtain the same effect, with dental care. Failure to recognize or to consider drug abuse can result in a wide range of repercus- 3) Habituation-the desire for a drug without any sions, somelife threatening. The purpose of this paper ill effect if its use is discontinued. is to present specific instances where drug abuse can 4) Potentiation-the combined effect of two drugs influence treatment planning and procedures. This is greater than the sum of their individual ac- will be done in the context of an abbreviated outline tions. of drug classification and definitions of words associ- 5) Physical dependence-a regular use of a drug to ated with drug abuse. allow normal physical functioning. Abstinence Drug Addicts’ Outlook on Dental Care results in withdrawal symptoms. Dental problems are a low priority item for most 6) Psychic dependence-pleasurable mental effects drug addicts. Obtaining drugs is the number one pri- from a drug so that users find its repetition ne- ority. It is commonfor drug addicts to eat unbalanced cessary to their well-being. meals. Foods in general are considered to be consti- 7) Withdrawal-characteristic reactions upon abrupt cessation of a drug which has produced Accepted: December4, 1979. a physical dependence.

94 Categories of Drugs and Effects The non-barbiturate tranquilizers produce a sense Narcotics act primarily on the central nervous sys- of well being and inability to cope. The most com- tem. Euphoria, relief of pain, tranquilization, sleep, mon brands are Dalmane, Equianil, Librium, Valium, and sedation are commoneffects of narcotics. Exces- Mellaril, and Thorazine. sive doses can lead to coma and death, generally The potentiating effect of alcohol and the tran- from respiratory failure. All narcotics are addicting. quilizers is great. In a one year period (1976-1977), Tolerance and withdrawal symptoms are also gen- there were approximately 57,000,000 prescriptions erally found. Relapse results from the pressures of written for Valium in the United States, making it the anxiety, depression or craving. number one prescription drug in this country. 3 With The most common trade and street names of nar- approximately 109 million alcohol users, this makes cotics are opium (blue velvet), morphine (M), the combination usage very common. deine (schoolboy), heroin (smack, junk), demerol Solvents and inhalents are generally regarded to (demies), and methadone (meth). The chief active cause a rapid heartbeat, relaxation, euphoria, dizzi- ingredient in opium is morphine. Heating morphine ness and headaches. The most common items abused in the presence of acetic acid produces heroin. in this category are glue, paint, aerosols, amyl nitrite, Amphetamines and related stimulants directly stim- butyl nitrite and nitrous oxide. ulate the central nervous system and produce euphoria for extended periods. These "uppers" can be addict- Significance of Addiction ing and can produce psychotic behavior. The most Three important questions for the dentist to ask are: commonly abused stimulants are cocaine (coke, snow), benzedrine ( bennies ), dexedrine (dex, speed (1) What drugs (if any) has the patient taken? (2) methedrine (meth), preludin and ritalin. Lack of ap- Is the patient on drugs at the time of the ap- pointment? petite, prolonged increase in metabolism, and inabil- (3) Did the patient ever iniect an addicting drug? ity to sleep for extended periods are side effects. With the abuse of speed, risk increases in direct proportion Iniection of a drug presents two problems. First, to"2 the amount used. "Speed does kill. patients who have "mainlined" drugs have a higher Commonstimulants are caffeine, and nicotine. incidence of hepatitis, and could be carriers. Repeated Barbiturates and related sedatives (depressants, use of unsterile needles increases the hepatitis risk for downers) slow down the heart and lower the blood the addict. Health professionals who come in contact pressure. All downers can destroy brain cells. With- with known drug addicts should be gloved, masked, drawal generally requires medical attention because and/or wear either glasses or safety goggles. All in- seizures can occur. Grand mal convulsions are com- struments should be routinely sterilized using ac- mon during withdrawal. The most commoncategories cepted procedures to kill the hepatitis viruses. Second, of sedatives are alcohol (the most deadly killer in the heart valve complications have been reported in nar- Western world today), Amytal (blues, downers), cotics addicts. 4 Agents used to dilute the drugs can Nembutal (yellows), phenobarbital (bennies), contribute to sub-acute bacterial endocarditis. Cutting onal (reds), Tuinal (rainbows), and Quaaluds. agents include talcum powder, quinine, sugar, baking Hallucinogens and cannabis produce changes in soda, and powdered milk. These agents can also act mood and behavior. They are non-addicting but tol- as a source of septic or non-septic emboli for long erance to these drugs builds rapidly, except apparent- periods of time after the treatment with resulting bac- ly to mariiuana. There are no withdrawal symptoms; teremia. Patients with a history of iniection of drugs the effects are primarily psychological with a wide need routine prophylactic antibiotic therapy as rec- range of manifestations. The effect seems to be re- ommended by the American Heart Association for lated to the expectations of the user, the setting in heart patients. which they are used, the unknown dosage level, and Some patients feel they need to be "high" to have the presence of impurities. The most commondrugs the courage to go to the dentist. Do not treat patients in this category are: hashish, mariiuana (grass), LSD while they are under the influence of a drug. (acid), mescaline (cactus), peyote (buttons), Technical procedures are no different for addicts psilocybin (magic mushrooms). The most widely and non-addicts. The dental materials used and the used drug of this category is marijuana. mechanical procedures utilized are the same as those PCP (angel dust) is an abused drug readily avail- used with non-addicted patients. Extended and ex- able in rural areas. It is an animal tranquilizer which tensive procedures should be limited to those patients causes pseudo-psychedelic reactions. PCP is danger- showing the interest to take care of the treatment. ous because of the inconsistency of the action and the Interim or temporary treatment could be considered if unusual side effects. there is some question as to the patient’s ability or

PEDIATRIC DENTISTRY Volume2, No. 2 95 desire to complete the treatment. Prevention should 1) A tendency for the patient to look off into be emphasized. space. 2) Moodiness. Case Histories 3) Sudden carelessness in appearance, especially C. J., a 16-year-old female, was referred to the au- if he or she has been well dressed in the past. thor by the local drug abuse program. During an 4) Drowsiness. initial interview, it was determined that she was in- 5) Laughing too much at things others do not iecting heroin as well as being an alcoholic. No drug think are funny. had been taken for 1 month. She had been experi- 6 The appearance of intoxication without the menting with abusive drugs for 4 years. Because of odor of any alcohol. the history of the injection of heroin, it was determined 7 A "hopped-up" appearance-bright shiny eyes. that appropriate antibiotics should be given to the 8 Changesin the size of the pupils of the eyes not patient before any bacteremia producing dental pro- accounted for by changes in light intensity, cedures. As the patient was not allowed to carry oral 9 Possession of pills, capsules, or iniection equip- medication, bi-cillin 1,200,000 units was iniected IM. ment. A panorex, anterior occlusal and posterior bitewing 10) Hallucinations or convulsions are the signal for 5 radiographs were completed. An oral examination was immediate medical attention. done with carious lesions noted. All teeth had to- bacco stains. Oral hygiene was poor. Marginal gingi- vitis was noted. A scaling, prophylaxis and stannous Conclusion fluoride treatment were completed. Local anesthesia Drug addiction among teens and preteens is in- was administered and three permanent teeth were re- creasingly common.Several attitudes of drug addicts stored. The final appointment also required the ad- are pertinent to dental care. Care of the dentition is ministration of a prophylactic antibiotic. The three re- probably a low priority. A number of drug categories maining carious lesions were restored under local an- can be abused with a wide range of effects. Addicts esthesia. The patient completed the drug abuse pro- injecting drugs pose two significant problems. Hepa- gram and left the city. titis may result from use of unsterile needles by the D. W., a 17-year-old male, was referred to the au- addict. Sub-acute bacterial endocarditis has been thor by the local drug addiction program. During the found in addicts and is presumed to be associated initial interview with the patient, it was determined with cutting agents (e.g., talcum powder) used to di- that he was taking a broad range of drugs, abusing lute the drug. whatever drug was available at the time (referred to as "garbage"). Drugs were being injected resulting in the need for prophylaetie antibiotie injections prior to dental treatment. The patient had not taken any drug References for over one month. A panorex, anterior oeelusal and 1. Rosenbaum,Charles: "Dental Examination of the Drug posterior bitewing radiographs were completed. The Addict," IndianaDental 1ournal, Vol. 36, No. 4, pp. 12-13, results of the oral examination were noted, Oral hy- July/August 1977. 2. Pawlick, Vic: ConscientiousGuide to DrugAbuse, 6th re- giene was poor. Marginal gingivitis was present. Bi- vised edition, DoIt NowFoundation. cillin 1,200,000 units was iniected IM. Oral hygiene 3. "Major Drugs: Their Uses and Effects," Playboy 25:159. instructions, scaling, prophylaxis, administrations of September1978. stannous fluoride and restoration of three posterior 4. Ayer, William and Cutright, Duane: "Dental Treatment teeth were completed. At two subsequent appoint- and Heart Valve Complicationsin Narcotic Addicts," Oral Surgery, 37:359-363. ments, prophylactic antibiotics were administered and 5. NIDAS.Vol. 4, No. 4. November1975. restorative care was done. The patient left the pro- gram before all necessary work could be completed.

Identification of the Drug- CHARLES H. ROSENBAUMis in private pedo- Addicted Patient dontic practice in South Bend, Indiana, and has been involved in the local substance abuse program for the If the patient does not identify himself or herself as past nine years as both a board member and the den- being on drugs, it is quite difficult for the dental tist for the clients. health professional to be sure of the status of a par- ticular patient. The following might be clues toward Requests for reprints may be sent to Dr. Rosenbaum identification: at 1005 E. LaSalle Avenue, South Bend, IN 46617.

DENTALCARE FOR ADDICTS 96 Rosenbaum