Dental patients who experience comorbid psychiatric and medical conditions present an elevated risk of medication misuse, abuse, substance use disorders, and overdose. The authors review the role of notable comorbidities in predicting the development of substance use disorder, including medical, psychiatric, and other psychosocial factors that can be assessed in general dental practice. Psychiatric disorders commonly cooccur with substance abuse, and these typically include anxiety disorders, mood disorders (major depression, bipolar), posttraumatic stress, as well as sleep and eating disorders. Medical disorders commonly found to be present with substance use disorders are also reviewed, including common cardiovascular and pulmonary disorders.
Key points
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Comorbid medical disease and psychiatric disorders are associated with an elevated likelihood of a patient’s misuse and abuse of controlled substances.
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Objective predictors can be assessed to inform dental practice and reduce the likelihood of overdose and the development/exacerbation of a substance use disorder.
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Dentists are advised to investigate substance use history with patients and manage the risk factors presented per a Controlled Substance Risk Mitigation checklist.
Psychiatric disorders can occur with the patient who also presents with simultaneous medical conditions, such as infections, gastrointestinal disorders, and other medical conditions. Both psychological and medical comorbidities can influence a patient’s treatment adherence, perception of pain, postsurgery recovery, health care utilization, and mortality. , When more severe mental health and medical comorbidities are present, health care costs and utilization are increased, and eventually a “morbidity burden” for the patient is seen.
A patient’s biological, psychological, and social factors (biopsychosocial factors) impact the risk of developing a substance use disorder (SUD), along with the risk of developing dental pathologic condition, for example, chronic masticatory dysfunction and temporomandibular disorders (TMD). Within chronic pain populations, premorbid psychological factors, including depressed mood, perceived stress, and above all else, somatization, reliably predict the new-onset and persistence of TMD conditions to the degree that the relationship between TMD and psychological factors substantiate the claim of causality. Patients with psychiatric diagnoses also pose a higher risk of presenting with decayed, missing, or filled teeth. For example, a sample of 5,076 patients with psychiatric diagnoses had a 2.8 greater likelihood of having lost all their teeth compared with the 39,545 persons in comparison groups. These untoward consequences underscore the need for the dentist to better assess and manage a patient’s psychiatric and medical comorbidities. The presence of these risk factors needs not derail treatment. Patients can be counseled when they are identified, with guidance on management in order to achieve better clinical outcome with overall dental care. In addition, communication with other health care providers should always occur, including the patient’s primary treating medical clinicians or cotreating mental health practitioners.
When assessing risk for the development of SUD, dental practitioners typically tend to focus on the negative predictors that might be present. Conversely, some argue that more attention should be paid to positive factors that lower risk and promote successful treatment of a SUD. Similar to risk factors, protective factors are dynamic and longstanding conditions. Stability in family, interpersonal, and professional relationships are commonly recognized protective factors. Protective factors reduce the likelihood that an individual will abuse drugs. These elements need to be recognized by the clinician and reinforced with the patient. Nonetheless, recognizing and reinforcing protective factors does not absolve the clinician of conducting a thorough assessment of controlled substance risks.
Substance use disorder and related comorbidities
Most patients with severe mental illness may also display symptoms that meet the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for SUD ( Box 1 ). Any mental disorder is considered serious when it imparts significant functional impairment that limits normative life activities. The authors typically see these impairments with psychotic disorders, schizophrenia, and moderate to severe depression. SUDs are characterized by a pervasive display of behavioral and cognitive patterns, amid physiologic symptoms, that persist despite negative consequences of repeated drug use. There are also specific, SUD-related criteria related to the effects of the particular substance being misused, for example, there is a difference between the intoxication and withdrawal properties of opioids versus alcohol.
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Other (or Unknown) Substance Use disorder
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A. A problematic pattern of use of an intoxicating substance not able to be classified within the alcohol; caffeine; cannabis; hallucinogen (phencyclidine and others); inhalant; opioid; sedative, hypnotic, or anxiolytic; stimulant; or tobacco categories and leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
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The substance is often taken in larger amounts or over a longer period than was intended.
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There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.
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A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
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Craving, or a strong desire or urge to use the substance.
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Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
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Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
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Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
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Recurrent use of the substance in situations in which it is physically hazardous.
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Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
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Tolerance, as defined by either of the following:
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A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
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A markedly diminished effect with continued use of the same amount of the substance.
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Withdrawal, as manifested by either of the following:
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The characteristic withdrawal syndrome for other (or unknown) substance (refer to Criteria A and B of the criteria sets for other [or unknown] substance withdrawal, p. 583).
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The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
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Specify if:
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In early remission: After full criteria for other (or unknown) substance use disorder were previously met, none of the criteria for other (or unknown) substance use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the substance,” may be met).
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In sustained remission: After full criteria for other (or unknown) substance use disorder were previously met, none of the criteria for other (or unknown) substance use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the substance,” may be met).
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Specify current severity/remission:
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305.90 (F19.10) Mild: Presence of 2–3 symptoms.
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(F19.11) Mild, In early remission
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(F19.11) Mild, In sustained remission
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304.90 (F19.20) Moderate: Presence of 4–5 symptoms.
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(F19.21) Moderate, In early remission
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(F19.21) Moderate, In sustained remission
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304.90 (F19.20) Severe: Presence of 6 or more symptoms.
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(F19.21) Severe, In early remission
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(F19.21) Severe, In sustained remission
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As of 2019, nearly 20.3 million Americans aged 12 and older met criteria for an SUD. This number equates to ∼8% of all Americans. With drug initiation rates exceeding the birth rate, it is likely that dental practitioners will encounter patients who fall under this population statistic regardless of where they practice in the United States. The mortality from opioid overdose is shown to be even higher when the patient has other comorbid psychiatric disorders, including posttraumatic stress disorder (PTSD), bipolar disorder, and schizophrenia.
It is estimated that more than 50% of psychiatric patients have a co-occuring SUD. If the patient has 1 SUD, odds are that the patient also has a second. For example, a patient who arrives at a dental practice with a history of longstanding alcohol use disorder may also be at greater risk for developing concomitant opioid use disorder. Among those with any lifetime SUD, 40% also had an anxiety disorder, and nearly 30% were found to have a mood disorder. The odds of someone with a mood disorder having an SUD are 2.5 times greater than the general population.
Although opioids remain a major national concern, other legal and illicit drugs also deserve attention with regard to their risk for abuse and fatal overdose. More significantly, polypharmacy presents an increasing problem encountered in dental practice. It typically manifests when a physician or dentist prescribes medications that may interact or complicate the patient risk status, for example, the combination of high-dose opioids and benzodiazepines results in an 8.9-fold increase in overdose risk. Complicating the risk, each of the patient’s health care providers may be unaware of medications not prescribed directly by them.
There are also cases whereby a single physician may be prescribing a complex regimen that increases patient risk. The authors have seen as many as 18 different controlled substances written by a single physician, occasionally with an added mix of different short and long-acting opioids. The overall dose exceeded the 90 morphine dose equivalent, a quantity suggestive of high overdose risk. The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, can offer guidance, specifically with respect to opioid dosing and polypharmacy, although there are controversies with respect to how effective the guideline has been implemented. In the case noted above, the general dentist typically is not the clinician prescribing the high-dose opioids or prescribing concurrent multiple controlled substances. Nevertheless, the dentist should aware of the risk in order to provide better management of the patient and engage in effective communication with other cotreating providers.
Other common psychiatric comorbid disorders
About 27% of dental patients report at least 1 mental illness, with anxiety reported second only to hypertension when considering all disease presentations. Following anxiety, commonly reported psychiatric disorders include depression, SUD’s, PTSD, eating disorders, insomnia, and bipolar disorder. Somatic symptom disorders also are seen in dental practices, especially when treating persistent orofacial pain disorders. Characteristics can include the presence of marked somatic complaints, including multiple concurrent pain conditions in the context of conflicting medical and dental diagnoses. Patients may show anxiety and significant frustration, often as a result of visiting multiple health care providers. Again, a consequence may be polypharmacy and escalation of the patient’s controlled substances by treating providers, the result being poor treatment outcome and increasing risk of an SUD.
Anxiety and Depression
With 33.7% of the population experiencing an anxiety disorder in their life and an estimated 20% of adults diagnosed with an anxiety disorder in the past year, , a dentist can expect to encounter at least 1 patient with significant anxiety symptoms on a daily basis. In practice, anxiety persists as the most frequent comorbidity with only one-fourth of cases treated. Although dental practitioners tend to overfocus on dental phobias, other related anxiety disorders commonly cooccur with severe dental anxiety. The estimated 12-month prevalence of anxiety disorders in the general population ranges from about 11% to 18%, with a 1.5 to 2 times higher representation in women. , Distinguishable characteristics of an anxious patient typically take form through a protracted and amplified sympathetic arousal response, which develops into a fixed state of apprehension. The patient may report muscle tightness, elevated pain, fear, and avoidance of activity, as well as clusters of somatic complaints. Although some level of apprehension is normal with dental procedures, a high level of severity may suggest the presence of a psychiatric disorder. The steps to identify severe anxiety include a combination of efficient history documentation and observation. The dentist may also easily identify the patient with a severe anxiety disorder when they arrive on multiple medications intended to target their symptoms. Brief anxiety screeners are available and easily adapted to dental practice. For example, the General Anxiety Disorder Scale, 7-Item (GAD-7) is commonly used in primary care medicine and can be easily administered by the dental hygienist or dentist ( Table 1 ).
