Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use and abuse, coordinate care with medical providers, and build a trusting provider–patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits, and alternatives to opioids are important aspects of the best care of these patients.
The dental provider plays a key role in the care of special populations and must work in coordination with other medical professionals to provide optimal, individualized care.
Nonjudgmental patient–provider relationships are important to establishing trust and facilitate asking difficult questions.
Setting expectations for pain and discussing the alternatives, risks, and benefits of treatment options is an aspect of best practices.
Dental professional need to consider the risk of misuse and abuse, including diversion, of medications in these special populations.
The dental provider plays an important role in the treatment of special populations of patients, including adolescents, women of childbearing age, and the elderly. Although these groups may seem very different, they share characteristics that require special consideration by the dental provider, especially when prescribing pain medications. Providers best serve these patients by recognizing the unique needs and offering individualized, compassionate, and comprehensive care, in collaboration with their medical colleagues.
Treatment of any patient must begin with a comprehensive evaluation. This evaluation provides an opportunity to build trust and to recognize any areas that may require further discussion, and those that may require consultation with other medical professionals. A thorough review of the medical history should include a discussion of medical issues, past surgeries and hospitalizations, current medications, and known drug allergies. Discussion of past dental experiences, concerns, and areas that are worrisome to the patient can help to identify triggers that may make the patient uncomfortable. This time is ideal time to discuss psychosocial issues, including substance abuse concerns, support at home, and other pressures that may prevent the patient from fully engaging in the recommended treatment.
A critical first step in developing this dentist–patient relationship is creating an open and safe environment that facilitates honest discussion. Providers who are comfortable with exploring all topics during the initial examination and gathering a history are more likely to elicit honest responses from the patient. Adopting a nonjudgmental approach may help to put the patient at ease, increasing the likelihood of full disclosure of information regarding health history, social pressures, and any history of substance abuse or misuse. Dental providers who see this process as an aspect of their professional role are more likely to ask patients about these sensitive topics.
The development of a treatment plan should include focus on comprehensive care whenever possible, and the establishment of a “dental home” is important for the development adequate longitudinal care. Patients with special health care needs and vulnerable populations benefit from additional support to ensure that they have the resources to keep their appointments. Providing a supportive environment may provide sufficient incentive to encourage the patient to continue with needed treatment.
Including patients in treatment planning helps to support their feeling of autonomy and helps to clarify their priorities. A discussion of the risks, benefits, and alternatives in treatment should include the expectation of discomfort, the need for pain medication, and the desires of the patient. An explanation of procedures before performing them can help the patient to feel a greater sense of control and set the expectation for reasonable discomfort and a realistic timeline for healing. Honest and open discussion regarding the level of pain expected will lead to a discussion pertaining to prescriptions and contribute to boundary setting. There is an ethical obligation to treat pain, but the patient must be aware that the goal is not to treat until there is no pain; rather, treatment should continue to a point at which the patient believes his or her pain is at a reasonable level. This understanding may decrease the need for pain medication and the duration for which it is needed.
Patients should be encouraged to establish care with all necessary medical and mental health providers, and to adhere to recommended treatment and follow-up visits. Explaining the role of oral health in overall health, as well as the ways medical issues and medications impact oral health, may help the patient to recognize the role of the dentist in complete health maintenance. If patients mention not taking medication or following through with advice as recommended, it is helpful to follow-up and encourage them to speak to their physician without managing their medications on their own.
For the provider, it is important to have positive relationships with other local medical professionals to establish a referral network. Comfort in speaking to medical colleagues is an important tool in providing the best care possible for patients. Incorporating medical care and follow-up as part of the patient’s overall plan demonstrates the importance of such to the patient and allows the dental provider to be aware of the concerns of their medical colleagues.
The need to evaluate the risks and benefits of the prescribed pain medications in these special populations is substantial and can help to inform the decision of which medications to prescribe, as well as the dosage and duration of the prescription. We now have a better understanding of the risks of prescription pain medications, which relates to the ethical obligation to provide appropriate pain relief. The tenet of prescribing the lowest level appropriate to reach the desired effect is an important one, especially in these higher risk groups.
Asking difficult questions
Knowing how to address sensitive topics is a necessary skill for all health care providers. Avoiding uncomfortable topics is likely to prevent a provider from learning important information that is key to the appropriate treatment of the patient. Psychosocial issues, such as family dynamics, safety, and drug and alcohol experience should be tantamount to the exploration of commonly explored medical issues, such as a family history of heart disease or diabetes. Establishing an open and nonjudgmental environment can lead to a discussion in which a patient is willing to disclose information that is critical to proper diagnosis and development of an ideal treatment plan.
Another important part of asking difficult questions is being self-aware as a provider, recognizing one’s own triggers and issues, and avoiding bringing one’s own preconceived notions into the conversation. It is important to stay emotionally neutral to keep the discussion focused on the patient. Taking time to recognize and address one’s own concerns outside of the encounter will allow the dental provider more freedom when speaking to his or her patients.
Adequately explaining a treatment plan to the patient, and the way ancillary treatments play into it, is essential. After evaluating the patient and determining treatment options, careful consideration of whether his or her pain can be treated by alternative sources is necessary. This process should include a discussion with the patient regarding the expected course of recovery, symptoms about which the patient should be concerned, and pain relief options based on current best practices. The setting of expectations is beneficial to both the patient and the provider.
There may be some resistance from patients if they feel the recommended course of treatment will not be adequate. Accordingly, the use of guidelines, when available, is a helpful tool to reassure the patient and allow the clinician to maintain best practices. The use of a patient contract may be considered to formalize the expected behaviors, treatment, and follow-up. Any time there is concern relating to language, literacy, or cultural limitations, additional resources should be used.
Comprehensive dental care is a lifelong commitment that should be stressed to the patient. Follow-up with medical colleagues and, if needed, addiction referrals, should be encouraged.
Assessing risk factors
Special populations are at risk of harm associated with potential misuse of medications, as well as diversion of their medications for nonmedical use by others. Diversion of medication is the redirection from the intended, lawful use for which it was prescribed to another person for a use unintended by the prescriber. This unlawful use may be due to family, societal, or economic pressures. Patients may keep excess medication just in case, which is a potential problem because someone may find it and use it for nonmedical purposes. Patients have reported using pain medication to trade for other medications or asking for a prescription so they can give it to family members who either use it themselves or sell it.
An important way to decrease diversion is through education of the patient by the provider. Education to better understand the harms of excess prescription opioids, help to recognize the signs of misuse, and consider potential for diversion is essential. Appreciating the value of the medication for nonmedical use and therefore the incentive of some patients to misrepresent pain to obtain prescription medication in excess of what is needed is important to understanding the problem. The use of checklists by providers, such as the Controlled Substance Risk Mitigation checklist, can help dental professionals to better evaluate a patient’s potential for abuse. Increasing physician awareness in these areas may encourage altering dosages before writing a prescription for an opioid.
Although there is no indication that emotional trauma is a proximate cause of substance abuse, the relationship between post-traumatic stress disorder (PTSD), substance use disorders, , and treatment-resistant pain conditions is well-established. In another article in this special issue, the authors address the issue of PTSD and substance abuse risk in greater depth. Women are twice as likely to experience trauma-related PTSD than men, with co-occurring rates of substance use disorder ranging from 25% to 50%. In a recent study with a large population sample, subjects having clinical PTSD had a 2.56-fold increase in joint pain, and a meta-analysis has confirmed the strong relationship between various chronic pain conditions and PTSD. The role of central sensitization is most commonly discussed as an underlying mechanism with respect to the relationship between chronic pain and trauma, although there remains a debate regarding clear causation. Kindler and colleagues argue that their results “should encourage general practitioners and dentists to acknowledge the role of PTSD and traumatic events in the diagnosis and therapy of TMD, especially in a period of international migration and military foreign assignments.” Given high rates of co-occurrence with substance use disorders, we similarly reason that a thorough assessment should address substance use risk, while acknowledging PTSD as a significant comorbid risk factor.
The adolescent patient
Adolescence is a transitional phase between childhood and adulthood that is marked by a growing sense of independence from parents or guardians. Adolescence is a time when individuals engage in more risk-taking behavior, which is thought to be due to the maturing brain’s reward centers developing faster than the control centers. Caring for adolescent patients requires an understanding of the biologic and emotional changes that the adolescent undergoes, to provide appropriate guidance and support as a health care provider. The establishment of a trusting relationship, asking direct questions regarding drug and alcohol use, engagement with parents or guardians, and, when needed, referral to other medical resources are particularly important during this developmental phase.
As the adolescent works to establish autonomy, there are legal and ethical limitations regarding to what they can consent on their own. Conversations and decision making should involve the parents or guardians if the patient is under 18, or if the patient is 18 or older and wishes to have parents present. Adolescent 18 years and older must consent to discussion of their care, regardless of whether they are still on their parents’ insurance or if parents are paying for their care. Even for minor patients, it is helpful to have a private conversation to allow for disclosure of a history of substance use regarding which they do not want their parents to know. Assumptions should not be made about an adolescent’s support system, and offering support from sources outside the family may be helpful in cases of suspected family problems with substance abuse.
Support systems play a crucial role during all stages of life, but adolescents are particularly vulnerable to the impact of their home life. During the teen years, a growing sense of independence often means that adolescent patients are more likely to be responsible for their own medication management, making nonmedical use more likely. Engaging parents or guardians in the process and clearly defining the expectation that the parent or guardian maintains responsibility for securing and dispensing medications may decrease the potential for nonmedical use or diversion. Families should be encouraged to have discussions regarding their own expectations relating to nonmedical opioid use, so the adolescent has clear boundaries regarding what constitutes safe and acceptable behavior.
Some adolescents may not have strong support systems at home and may benefit from referral to community resources for social work services, mental health providers, or addiction support organizations. Teens who have experienced a caregiver with substance abuse are considered at higher risk of substance abuse themselves, as well as mental health issues and accidental overdose. Substance use during adolescence may limit the quality of social interactions, leading to isolation and deterioration of support systems.
Dental providers should question changes in appearance, disorientation, erratic behavior, changes in pupil size, and injuries to the teeth or soft tissues as possible signs of substance abuse. Initial signs of mental illness may occur during adolescence, so sensitivity to such is important, because it may present in various forms. Findings of concern should be discussed with the patient in an open and honest fashion, and include discussion with parents or guardians as well as consideration of referral to other medical professionals, if needed.
It is important to recognize that prescription opioid medication for a dental procedure such as a third molar extraction may represent the initial exposure for an adolescent, and use before high school graduation has been associated with a 33% greater risk of subsequent misuse. Interestingly, this correlation is particularly strong in adolescents without histories of drug use, and among those who have negative feelings regarding illegal drug use. This finding highlights the importance of comprehensive counseling of patients and families regarding the dangers of nonmedical prescription drug use, which may not be initially clear to them. Although a majority of patients who reported nonmedical use of prescription opioids while in high school no longer reported it within 3 years, the high abuse potential of these medications and risk of diversion makes judicious prescribing to this group imperative.
There are no absolute indicators of which adolescents are at highest risk of prescription opioid abuse, although it has been linked to heavy alcohol and marijuana use. Therefore, screening questions that are sensitive to adolescents should assess past use of alcohol and drugs, as well as potential opioid abuse risk. Allowing screening questions to be answered anonymously and without the involvement of parents has been shown to increase responsiveness. The use of alcohol and marijuana increases the likelihood of nonmedical use of prescription opioids, so positive responses regarding such should prompt increased counseling if an opioid prescription is deemed necessary.
If an adolescent presents with pain or will be undergoing a procedure that will likely cause discomfort, opioid alternatives should be considered first. Although risk assessment of abuse potential is critical in determining which medications to prescribe, it is important to first familiarize oneself with what is appropriate in the clinical situation. Nonopioid management should be attempted whenever reasonable. If opioids are deemed most appropriate to treat pain, then the provider must have a frank conversation with the patient to discuss the purpose of the medication, the goals of use, and abuse potential, and warn against using the medication for nonmedical reasons or sharing the medication. Additionally, more frequent follow-up is recommended as an element of the treatment plan.
Women of childbearing age
Women of childbearing age, approximately from 18 years to 44 years of age, offer unique challenges relating to prescribing pain medications. This age range corresponds with a time in a woman’s life when she is most likely to develop an addiction. It is also a period during which she is most likely to become pregnant, planned, unplanned, or unknown, which must be considered when prescribing medications that could be detrimental to a developing fetus. Careful medical history taking and asking about changes in health and possible pregnancy are important. Women should be encouraged to seek routine medical care especially if they are, or suspect they might be, pregnant.
Pregnancy can be a challenging time for a woman and those with a history of trauma may struggle with a range of increased medical concerns, exacerbation of pain conditions, as well as worsening of some psychiatric disorders. Creating a warm, welcoming, and nonjudgmental environment for treatment will make patients more comfortable and increase the likelihood that they will return for care. Medical care and follow-up during pregnancy are very important to ensuring a healthy baby and expectant mother; asking about recent medical visits and encouraging compliance with the obstetrician’s recommendations should be part of every dental visit.
Woman of childbearing age with substance abuse disorders are much more likely to have an unplanned pregnancy and receive less prenatal care, making this an important consideration in prescribing pain medication to this group of patients. Careful questioning and education to ensure they understand the risks of not disclosing a possible pregnancy is important when determining the class of medication to prescribe in this group. The question of pregnancy status is often and easily asked when taking dental radiographs; a similar approach can be used for this purpose.
Substance use during pregnancy is not rare, with national reporting indicating more than 8% of US pregnant women “using an illicit substance in the past 30 days.” Pharmacy data indicate that approximately 20% of pregnant women on Medicaid and almost 15% of pregnant women with private insurance filled a prescription for opioids in the previous year, suggesting that opioids are frequently used as a means to manage pain in this patient population.
Extended opioid use in pregnancy can lead to an increased risk of congenital malformation. Continued use of opioids in pregnancy increases the risk of neonatal abstinence syndrome, a complex condition resulting from the cessation of drug exposure after birth. The syndrome can present as irritability and excessive crying, feeding issues, hyperthermia, and, less commonly, seizures. The mechanism is not well-understood, although it is thought to be due to changes in dopamine, norepinephrine, and serotonin in these babies who have prenatal exposure to opioids. There are many prenatal maternal behaviors that are thought to impact the presentation of the newborn, including the specific substance and duration of use, treatment, or opioid substitution program participation, and degree of compliance with prenatal care. There is no standard treatment for these babies, although treatment generally includes the provision of a calm environment and frequent feedings to decrease hunger.
Women using opioids while pregnant may be able to participate in an opioid substitution program, which will not eliminate the risk of neonatal abstinence syndrome, yet can decrease the riskier behaviors associated with drug seeking and allow for increased compliance with routine medical care. Opioid agonist therapy, such as methadone or buprenorphine, is considered preferable compared with complete cessation because it decreases withdrawal symptoms and chances of relapse; however, it must be managed by addiction specialists trained in pregnancy, which may be difficult to find in medically underserved areas.
Although adherence to prenatal care and participation in substance abuse treatment may seem like obvious choices for an expectant mother, the legal ramifications can be overwhelming for some women. Many states consider drug use during pregnancy, including opioid substitution programs, to constitute child abuse. In these states, a woman using opioids is more likely to have a child removed from her care. Treatment options for dependence during pregnancy are crucially important, yet there is a lack of treatment facilities available for these patients. Sadly, those with fewer resources and reduced socioeconomic status tend to have the most difficult time finding highly specialized care, despite their high-risk status.
Dental providers should question changes in appearance, disorientation, erratic behavior, injuries to the teeth or soft tissues, and drug-seeking behavior as possible signs of substance abuse. Concerning findings should be discussed with the patient in an open and honest fashion, as well as consideration of referral to other medical professionals, if necessary.
Pregnancy can be a challenging time in a woman’s life, and those with substance abuse issues, or risk factors, warrant additional attention. Sharing the dental diagnosis and recommended treatment with the patient and allowing her to participate in treatment planning demonstrates respect for her autonomy and encourages compliance. An open discussion regarding the expected discomfort and pain relief options that can be offered may help to decrease the need for prescription pain medication. When medication does need to be prescribed, it should be done carefully and in conjunction with obstetrician clearance. Before performing any dental work, a consultation with the physician is recommended; this step will also illuminate whether the pregnant patient is actually under the care of a physician. If a pregnant patient has not sought prenatal care or has not been seen recently, the dental professional provides a vital service by insisting on examination with an obstetrician before proceeding.
Medical advances and lifestyle changes have resulted in a longer life expectancy, with almost 15% of Americans currently over the age of 65. , There are physiologic and emotional changes as we age that need to be taken into consideration for treatment of this population. Sixty percent of older adults manage 2 or more chronic conditions. , In addition to other medical considerations, a provider must also consider the medications used to treat them and how that impacts dental care. In response to a growing concern regarding the long-term impact of nonsteroidal anti-inflammatory drug use and potential for undertreatment of pain in the elderly, there was a shift toward opioid prescriptions, leading to a doubling of opioid prescriptions in older adults between 1999 and 2010, with 10% of clinic visits for older adults involving prescription of an opioid.
Dental treatment of the elderly can be very complex. The aging process, which is associated with taking more medications, often results in a decrease in the quantity and quality of saliva. This factor, combined with heavily restored dentition and potential issues with dexterity and brushing, can lead to a decline in the state of oral health and the need for significant dental procedures. Even patients who previously had few dental needs can find themselves with a failing dentition if care is not taken to avoid the problem. The financial ramifications can present an additional challenge to those on fixed incomes.
Older adults should be connected with a primary care doctor to help manage the complexities of aging, and may consider someone specializing in geriatric medicine, if available in their area. Confirmation that all medications are being taken as prescribed should be a routine part of every dental visit, as well as asking about changes in health, recent hospitalizations, and any falls. Inquiring regarding these issues reaffirms to patients that they are important concerns and need to be discussed and followed up with any health care provider. It can be helpful to encourage older patients to maintain a written or typed list of current medications and names of their physicians.
Mobility and ambulation are concerns for the elderly, especially given the morbidity and mortality associated with injuries from falls, which are more common, independent of opioid use. Prescription medications that may alter the patient’s balance or decision making should be approached with caution. Inappropriate or excessive use of opioids have been found to result in an increased risk of injury, especially for the elderly with new opioid prescriptions. The sedative side effect of medications should be discussed, especially for patients who continue to drive. Careful, complete, and open discussions with these patients are important to assess and counsel regarding these risks, and for them to understand which areas are of greatest concern.
Elderly patients may require assistance from family or friends, and an open discussion of their support network should occur at the first visit and be reviewed when there is a change in health or life events, such as moving or the death of a spouse. Patients should be encouraged to discuss challenges at home, especially pertaining to dexterity required for oral health home care or taking medications, as well as concerns regarding safety in the home. Elder abuse is a serious issue, which may be viewed as physical or emotional abuse or as neglect. It may include withholding or diversion of medications, both for medical conditions and pain relief. Many states have reporting requirements if elder abuse is suspected. Providing local resources for the elderly can help them to take advantage of local community offerings for older adults that may help them to access the services and connection that they need.
Physiologic changes with aging may include changes in drug absorption, metabolism, and excretion. These changes may be augmented or enhanced by disease processes or other medications. Thorough accessing of health history and discussion may illuminate areas that the patient has forgotten to disclose. For example, it is important that the dental provider has a complete list of current medications that are each linked back to a medical condition being treated. Medical consultation with the patient’s physician is encouraged when there is any question of the patient’s ability to be an accurate health historian. A discussion of health history and the treatment plan with a family member may be helpful, but can only occur with the express permission of the patient, unless there is a legal finding that an older individual is no longer competent to make his or her own medical decisions.
Patients may experience an increase in pain as they age owing to many factors, including neuropathic, musculoskeletal, inflammatory, and mechanical/compressive. Given the complex causes of pain in the elderly, there should be open discussions regarding the objective that treating the pain may not lead to complete relief, but rather a decrease to a level less likely to impact independence and quality of life. In general, pain in the elderly is best treated with acetaminophen and nonmedication options, such as physical therapy, whenever possible. When there is no option other than opioids, it is best to stick to those with the shortest duration of action and at the lowest effective dose.
Sudden mental status changes can occur owing to a variety of causes and are not considered a normal part of aging. Dementia is not well-understood, but there is some evidence that opioids may increase the risk of developing it over time. Cognitive decline and confusion are potential issues and must be considered in choosing medications to prescribe and the possible impact they may have directly on the patient or through drug–drug interactions. Changes in the way the body metabolizes medication as we age may result in overmedication, often resulting in confusion. If a significant change has been noted in an established patient, a consultation with his or her physician is warranted immediately.
There is a decreased risk of death owing to opioid overdose in the elderly that, along with the perceived decreased risk of addiction and the multiple medical issues that may result in pain, results in elderly people being more likely to fill an opioid prescription. However, nonmedical opioid use was found to be associated with a greater rate of alcohol abuse and mental health conditions. The elderly population is more likely than the general population to receive prescriptions for longer duration and at higher doses. Patients in long-term care facilities are especially vulnerable to the misperception that opioids are not harmful to the elderly.
Dental providers should question changes in appearance, disorientation, erratic behavior, injuries to the teeth or soft tissue, and increased reports of falls or injuries as possible signs of substance abuse. Concerning findings should be discussed with the older patient in an open and honest manner, as well as consideration of referral to other medical professionals, if appropriate.
Elderly patients benefit from comprehensive dental care, and when they present with pain, a proper diagnosis is a necessary first step. Once a treatment plan is developed, the expectation of discomfort can be determined and a prescription can be provided, if necessary. Despite concerns with opioid prescriptions in this population, when used appropriately they serve an important role in improving quality of life. Short-term, appropriate use can decrease pain and improve sleep in the elderly. ,
Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use/abuse, coordinate care with medical providers and build a trusting provider-patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits and alternatives to opioids are important aspects of the best care of these patients.
Partial support was received for the preparation of this article through a grant from “The Coverys Community Healthcare Foundation”.