Assessment and Management of the High-Risk Dental Patient with Active Substance Use Disorder

Every dentist cares for patients with a history of substance use disorder (SUD), regardless of a patient’s socioeconomic status, education, or ethnicity. SUD is a global epidemic, with approximately 8% of the general US population meeting diagnostic criteria for a SUD and more than 20% of the global population experiencing a SUD. The importance of understanding how to identify substance use, manage patients with a SUD, and offer appropriate referral is essential for all dental professionals. In 2005, the American Dental Association published, “Statement on Provision of Dental Treatment for Patients with Substance Use Disorders.”

Key points

  • The dental provider plays a key role in the care of patients with substance use disorders, working in collaboration with other medical professionals to determine the appropriate level of care and necessary referrals to promote optimal access, support, and treatment.

  • Screening, brief intervention, and referral to treatment (SBIRT) is an approach to delivering early intervention and treatment, providing a framework for dental providers to assess patients through the use of brief validated screening tools, communication to increase awareness and motivation toward change, and access to specialty care when appropriate.

  • The frequency and severity of medical emergencies related to patients presenting with substance use disorder in dental settings can be mitigated through application of the SBIRT model.

  • Nonjudgmental, destigmatized, and compassionate communication between patients and providers is necessary to establish a therapeutic alliance and effectively promote recovery and patient safety.

Introduction

Opioid prescribing by dental providers has decreased steadily since 2012, yet the shift in prescribing trends has fallen short of implementing a comprehensive screening and referral paradigm for patients at risk for misusing prescription or illicit opioids or patients with an active substance use disorder (SUD) or opioid use disorder ( Box 1 ). Furthermore, the integration of risk mitigation assessments and mental health referrals has not been widely implemented despite their utility in averting both high-risk prescribing and inadequate follow-up care. This situation exists in stark contrast to the resounding data that indicate the dental setting is an opportune platform to implement screens, deliver brief interventions, and provide appropriate referrals. Therefore, it is within the purview of dental practitioners not only to identify who is at risk of developing an SUD but also to treat and offer guidance to help patients navigate health care systems and effectively remove the barriers that interfere with their access to care.

Box 1
American Dental Association, October 2005, “Statement on Provision of Dental Treatment for Patients with Substance Use Disorders”
From American Dental Association. Statement on provision of dental treatment for patients with substance use disorders. Available at: www.ada.org/en/advocacy/current-policies/substance-use-disorders . Copyright © 2005 American Dental Association. All rights reserved. Reprinted with permission.

  • 1.

    Dentists are urged to be aware of each patient’s substance use history and to take this into consideration when planning treatment and prescribing medications.

  • 2.

    Dentists are encouraged to be knowledgeable about SUDs—both active and in remission—in order to safely prescribe controlled substances and other medications to patients with these disorders.

  • 3.

    Dentists should draw on their professional judgment in advising patients who are heavy drinkers to cut back and the users of illegal drugs to stop.

  • 4.

    Dentists may want to be familiar with their community’s treatment resources for patients with SUDs and be able to make referrals when indicated.

  • 5.

    Dentists are encouraged to seek consultation with a patient’s physician, when the patient has a history of alcoholism or other SUD.

  • 6.

    Dentists are urged to be current in their knowledge of pharmacology, including content related to drugs of abuse; recognition of contraindications to the delivery of epinephrine-containing local anesthetics; safe prescribing practices for patients with SUDs—both active and in remission; and management of patient emergencies that may result from unforeseen drug interactions.

  • 7.

    Dentists are obliged to protect patient confidentiality of substances abuse treatment information, in accordance with applicable state and federal law.

Dentists and dental hygienists play a critical role in the assessment and management of complex dental patients, and their role in opioid risk mitigation to date has been underemphasized. Dental practitioners have enduring relationships with their patients and are in a strategic position to utilize brief standardized assessment approaches. For example, screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, integrated, public health approach to inform treatment planning by identifying patients at risk for SUD (or those engaging in risky alcohol and drug use). As reviewed in other articles in this issue, the National Institute on Drug Abuse Quick Screen and its integrated SBIRT assessment pathway advise dental practitioners to assist in screening, provide brief interventions (eg, 5–10 minutes), and refer to treatment. Dentist practitioners already possess considerable knowledge of prescription opioids, because they provide treatment guided by established prescribing standards, which necessitate SUD risk assessment in managing acute pain. This article is designed to review the goals of assessment by defining the methodology relevant to the contributions of the entire dental team.

Identifying substance use disorder in the dental practice

A detailed medical and psychosocial history is necessary to properly screen and identify a patient with a potential SUD. The medical history also must include a family history (including history of SUD) as well as current medications, smoking status (tobacco and cannabis), alcohol use, and illicit drug use, denoting both frequency and administration of the substance (vaped, injected, inhaled, and so forth). The type and method of administration of each substance may be important in identifying a patient’s likelihood of contracting an infectious disease, risk of mental and physical health consequences, and adherence to treatment recommendations. Cicero and Ellis observed how some, but not all, patients who orally administer opioids may move to other dosing routes like insufflation or intravenous injection, both delivery systems associated with increased exposure and vulnerability to infectious disease. In addition to infectious diseases, intravenous use is associated with a 100-times increased likelihood of developing deep vein thrombosis compared with the general population.

The NM ASSIST (National Institute of Drug Abuse Modified Alcohol, Smoking, and Substance Involvement Screening Test) outline a more detailed investigation of drug use history if the results from the quick screen are positive; details on this screening approach are discussed in depth in other articles in this issue. Routine screening for alcohol use also should be performed using brief questionnaires, such as the AUDIT-C (Alcohol Use Disorder Identification Test for Consumption). The CUDIT-R (Cannabis Use Disorder Identification Test-Revised) can query for problematic cannabis use, another area of increasing interest for clinicians concerned about oral health. ,

Despite the availability of validated screening measures, stigmatizing factors related to substance use may have an impact on the accuracy of a patient’s self-report. Social desirability bias, legal implications of admitting to illicit activities, and implicit cognitive process are factors that may cause a patient to deny or underreport use of a substance. , The risk of collecting unreliable self-report data belies the need for dentists to be aware of physical and oral manifestations of drug use. There are several intraoral symptoms associated with substance use, such as rampant caries, poor oral hygiene, advanced periodontitis, xerostomia, a high percentage of missing teeth, traumatic lesions, and oral infection. , The opportunity for dentists to provide brief intervention and referral can arise from any dental encounter. Common oral symptoms associated with substance use are listed in Table 1 .

Table 1
Intraoral findings commonly found in patients with commonly abused substances
Drug Oral Manifestations
Alcohol
  • Oral mucosal discoloration

    • Stomatitis: red atrophic oral mucosa; yellow-brown discoloration

    • Glossodynia: atrophic red beefy tongue

  • Leukoplakia

  • Distinct halitosis (fruity acetone breadth)

  • Multiple caries and/or periodontal disease

  • Enlarged salivary glands (particularly parotid)

  • Xerostomia

  • Bruxism

  • Reduced tolerance to pain

Cannabis
  • Distinct greenish staining of tongue and oral cavity

  • Xerostomia

  • High risk for periodontal disease

    • Gingival hyperplasia

    • Alveolar bone loss

    • Clinical periodontal attachment loss

Chronic opioid use
  • Clenching, bruxism

  • Xerostomia

  • Increased susceptibility to periodontitis and dental caries

Cocaine
  • Dyskinesia

  • Jerky movements of the face uncontrolled

  • Xerostomia

  • Gingival attachment loss (test for potency by rubbing on gingiva)

  • Bruxism

Heroin/fentanyl
  • Teeth erosion due to frequent vomiting? From withdrawal?

Methamphetamine
  • Extensive caries

  • Characteristic meth caries

  • Chelation reaction that cleaves enamel from dentin

McNeely and associates discuss various factors related to dentists recognizing an SUD. The implementation of screens and the referral to treatment services were limited, however, to alcohol and tobacco and not evenly distributed among dentists, depending on their geographic region. It was proposed that the disparity in perceived utility of screens and the scarce application of them lies not in dentist aptitude, but rather in the majority of training curriculums that fail to include clinical opportunities and practice-based systems focused on SUD that could facilitate patient-provider discussions, support, and access to treatment.

Brief intervention and brief treatment

The component of SBIRT that follows screening is brief intervention and/or brief treatment. This 20-fold process offers dental clinicians the opportunity to promote patients’ insight and awareness concerning their substance use in order to assist with behavioral change. , In this step, the goal for the dental practitioner is to educate patients and promote their motivation to reduce or stop the use of harmful substances. The dentist should ask for a patient’s informal permission to receive feedback before advice is offered. Brief open-ended questions and motivational phrases may include, “Would you mind taking a few minutes to talk with me about your alcohol use?”; “Hello, I looked through your intake questionnaires. I’m worried about you. How are you doing?”; “I notice you have very advanced dental decay, which we may see with substance use. Could you talk with me about your health so that I can best support you?”; and “What connection do you see between your substance use and your dental findings?” To apply motivational interviewing principles, the dentist should try using language that acknowledges the autonomy of patients by emphasizing their personal choice. See Box 2 for examples adapted from Miller and Rollnick. The format provided allows dentists to offer several options for referrals or treatment recommendations, which can enhance a patient’s experience of choice and collaboration. Good chairside manner and a compassionate team approach make dental procedures less harrowing for any patient.

Box 2
Autonomy supportive language prompts

  • “In the end the decision is up to you, but I can describe some options if you’d like.”

  • “You may or may not agree with this idea…”

  • “If you wish, you could try…”

  • “I can’t tell you what to do, but I can tell you what’s worked for other patients.”

Despite an empathic and therapeutic alliance, patients may disagree with their provider. Dentists should remain noncombative and validate patients’ concerns before offering suggestions. Table 2 provides the 7 Es, proposed by Becker and associates as a method of evoking awareness within a patient presenting with pain. It is up to dental professionals to decide how to connect the conversation style to their practice. The result may look something like this: “For some people, taking opioids daily can actually make pain worse. If it’s all right with you, I can go over programs that have helped other patients manage their pain.”

Aug 5, 2020 | Posted by in General Dentistry | Comments Off on Assessment and Management of the High-Risk Dental Patient with Active Substance Use Disorder
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