Tobacco Cessation and Substance Use Disorders

Chemical ____ as a syndrome featuring persistent usage of a drug. difficulty in stopping and withdrawal symptoms. Chemically ____ people will go to great lengths to maintain access to the drug, often resorting to crime

dependence/dependent

Drug dependence is not limited to dependence on _____. Alcohol or drug dependence follows risky behavior. At this stage, alcohol or other drug use may no be compulsive or out of control.

illegal drugs

Many dependent people are still able to work, maintain family relationships, and friendships, and limit the use to alcohol or other drugs to certain time periods, such as weekends or evenings. However, is it also difficult for the impaired individual (and for others) to recognize the affects their substance use may be having on themselves, friends, coworkers and family members

True

Repeated use of alcohol or other drugs leading to failure to fulfill major responsibilities related to work, family, school or other roles. Repeatedly drinking or using drugs in situations that are physically hazardous, such as driving or operating heavy machinery when intoxicated, and repeated legal, familial and relationship problems surrounding the substance are all characteristics of _____

Dependence

A behavioral pattern characterized by drug craving, out of control drug usage, overwhelming desire to obtain a drug supply, drug use causing personal and legal problems, denial about the personal drug use, and continuing to use the drug despite personal and legal difficulties

Psychological dependence

____ is an adaptive state, occurring after prolonged use of a drug, in which discontinuation of the drug causes physical symptoms that are relieved by re-administering the same drug or a pharmacologically related drug

Physical dependence

A treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with _____ use substances or engage in behaviors that become compulsive and often continue despite harmful consequences

Addiction

Which statement best describes how addiction develops in the brain?

C. The brain may switch from a normal state to an addicted state after repeated use.

Why is addiction difficult to treat?

Because it causes long-lasting changes in brain structure and function that can persist even after stopping drug use.

Addiction is a __________ illness that worsens over time if left untreated.

progressive

Using drugs repeatedly over time changes brain structure and function in long-lasting ways.

What happens to the brain with repeated drug use over time

What is postulated about the brain after repeated drug use?

After a certain amount of drug use is consumed, the brain essentially switches from a normal state to an addicted state.

______ was one of the first public documents linking smoking to increased risk of cardiac and vascular disease. More recent research ties tobacco use to cancers of the mouth, pharynx, esophagus, lung, pancreas, and bladder. Additional health risks include diabetes, respiratory disorders, premature, low birth-weight infants, spontaneous abortions and periodontal disease

(Nicotine Use & Addiction) The U.S. Surgeon General’s Report on Smoking and Health of 1964

Elongated; black; brown; yellow or white papillae form in response to the solid and gaseous wastes of tobacco being trapped on the tongue’s surface. Slowed cell sloughing adds to this syndrome. Food and bacteria may be trapped in the papillae and cause halitosis

Black Hairy Tongue due to oral implications of cigarettes and cigar use

While saliva flow is generally reduced in chronic smokers, the act of smoking stimulates serous saliva flow. This can increase calculus production. Stain is generally present. The combination of stain and calculus may compromise the periodontal health of most smokers

Stain and Calculus due to oral implications of cigarettes and cigar use

Conditions such as necrotizing ulcerative gingivitis (NUG) is prevalent in smokers. Scientific evidence clearly shows smokers have more severe periodontal diseases than do non-smokers. Continued smoking is likely to compromise the success of periodontal therapy. More refractory periodontal patients are smokers (90%) when compared to the general population (25%)

Gingival and periodontal diseases due to oral implications of cigarettes and cigar use

candidiasis, nicotine stomatitis, smoker’s keratosis, pigmentation changes, and xerostomia

Additional oral changes smokers may also experience

The incidence of acute or chronic inflammation of the nasal lining of both the maxillary and frontal sinuses occurs 75% more often among smokers than non-smokers. This is attributed to the chemical compounds in tobacco

Sinusitis

Nicotine is a vasoconstrictor and reduces blood flow to the tissues, causing delayed wound healing, especially in the mouth where smoke lingers.

Ability to heal

Dry sockets are four times more prevalent among smokers. Typically, dry sockets occur when the addicted smokers returns to their habit too soon after an oral surgery, disrupting the delicate clot in a postoperative extraction socket

Ability to heal

A precancerous lesion of the oral soft tissue that consists of a white patch or plaque that cannot be scrapped off

Leukoplakia

Often associated with tobacco use. It can persist in an area with no pain or irrigation. These areas can develop into more serious lesions and should be examined carefully during a meticulous oral evaluation. Some ____ will regress if tobacco use is discontinued

Leukoplakia

When tobacco products are held in the mouth, it allows bacteria to flourish. Typically, bleeding is an indicator of gingival inflammation. With nicotine use and abuse, _______ can lead to reduced bleeding upon probing which may be give a false clinical indication.

vasoconstriction in oral tissues with chewing tobacco

Aggressive form of squamous cell carcinoma known as ____. In most cases, cessation of the habit prior to the development of the cancer results in the disappearance of the lesion and a return to normal mucosa

Verrucous Carcinoma

If the user of chewing tobacco chooses a tobacco product flavored or sweetened with a fermentable carbohydrate, there is _____, especially near the placement site

an increase in caries

Due to the irritating nature of the tobacco itself as well as the toxic chemicals released, there is a higher incidence of recession, especially adjacent to the placement site

gingival recession with chewing tobacco

A measured dose of nicotine delivered-taper down over time. Examples: transdermal nicotine replacement therapy (patch), nicotine polacrilex (gum), nicotine lozenge, nicotine oral inhaler

Nicotine replacement therapy

Sustained-release bupropion (Zyban)(wellbutrin), Bupropion blocks dopamine from surging after nicotine is inhaled/absorbed. Is an antidepressant that helps balance dopamine levels when nicotine starts to leave the body, preventing nicotine withdrawal symptoms, such as irritability, restlessness, and an urge to smoke again.

Prescription pharmacotherapies for tobacco cessation

____ blocks nicotine receptors in the brain- smoking does not provoke same response

Varenicline (Chantix)- a px pharmacotherapy for tobacco cessation

Nicotine from smoking

Absorption in lungs

Smokeless tobacco

Absorption in the oral cavity and intestines

Electronic Nicotine Delivery Systems (vaping) (ENDS) have shown oxidative stress and _____ tissue

cell death to epithelium

____ most efficient and effective method for detecting tobacco-related conditions in and around mouth

EO/IO examination

Bupropion SR, Varenicline Tartrate, COMBINATION THERAPIES Systemic med PLUS NRT, and Second-Line Medications are ALL

nicotine-free therapy

The first non-nicotine medication shown to be effective for tobacco cessation and approved by the FDA for that use

Bupropion SR (welbutrin, Zyban)

Blocks neural uptake of dopamine and/or norepinephrine

Mechanism of action for Bupropion SR

____ can be used in combination with NRTs (Nicotine Replacement Therapies). Take second dose 8 hours after first and with evening meal to reduce sleep disturbances, has not been shown to be an effective cessation method for adolescents, 20 years and younger

Bupropion

The second non-nicotine medication shown to be effective for smoking cessation and approved by the FDA for that use. Not currently recommended for use in combination with NTRs.

Vare nicline Tart rate (chantix)

A partial nicotine agonist (blocks nicotine receptors in brain). It also causes reduction in dopamine release. Always take after meals with full glass of water to reduce nausea. Take second dose 8 hours after first and with evening meal to reduce sleep disturbances.

Mechanism of action Vare nicline Tart rate (chantix)

Helping patient quit using tobacco becomes integral part of dental hygiene

care plan

All social tobacco use can lead to addiction, breathing second-hand smoke can impact nonsmokers, smokeless tobacco ____ alternative to smoking, oral health team can help patients become tobacco free

not safe

Natural Dopamine production is reduced through ____ could lead to addiction

repeated drug or alcohol use

No classic profile for ____

substance abuse

Effects of Alcohol intoxication, consequences of underage drinking, signs of AUD

clinical pattern of alcohol use

Genetics, biopsychosocial, and environmental are all

alcohol consumption etiology

Because alcohol will dehydrate the patient, their salivary flow may be compromised. An enlargement of the parotid salivary glands may be a sign of a chronic alcohol use problem. Educating the patient about the benefits of in-office and home therapeutic doses of calcium-phosphate fluoride varnishes and toothpastes will help to protect these patients from new or recurrent decay

Xerostomia

Drinking alcohol has been associated with oral cancer. Evidence suggests that this is because alcohol breaks down into ____, which can bind to the proteins in the oral cavity. This can trigger an inflammatory response in the body. In the most severe cases, cancerous cells can develop

acetaldehyde

Excessive alcohol use may damage the liver and bone marrow resulting in ____ during dental tx. If excessive bleeding is observed, treatment should be stopped, and digital pressure applied. Referral for medical evaluation and necessary blood coagulation tests should be requested before tx progresses

excessive bleeding

The drugs used in dentistry that are metabolized in the liver include amide local anesthetics and benzodiazepines. These drugs can have a reduced effect in patients who ____

use alcohol excessively

Neutrophilic phagocytosis is associated with periodontal disease. Alcohol also impairs ______, contributing to bacterial overgrowth which may lead to periodontal inflammation.

neutrophil function

High alcohol intake increases monocyte production of _____ in the gingival crevice which is associated w/ periodontitis

inflammatory cytokines (tumor necrosis factor-alpha TNF-alpha), interleukins-1 and 6)

when alcohol is suspected in the dental pt, management depends on whether or not the pt is intoxicated, shows signs of alcohol abuse or reports a substance use disorder on the health hx. A patient who comes to the appointment in an _____ and accompanied to their home by a responsible person

inebriated state should be rescheduled

Liver metabolism

metabolism of alcohol

____ a nasal spray that blocks the effects of opioids in overdose situations

Naloxone (Narcan)

Stimulants _____, and speed up metabolism.

increase cardiac and respiratory function

Methamphetamine (meth, speed) is taken orally, intranasally (snorting the powder), by intravenous injection, or by smoking. Meth users are ____

resistant to local anesthesia

Methadone (Dolophine, Methadose), Buprenorphine (Subutex) Buprenorphine/Naloxone (Suboxone), Naltrexone (Vivitrol/ReVia), and other medications are all

Drug withdrawal medications

A full opioid agonist, used in long-term maintenance for pts recovering from heroin or opioid addiction, can be administered 2.5-10 mg instravenously, intramuscularly, or subcutaneously every 8-12 hours. Can also be administered orally initially 20-30mg for the initial dose, additional 5-10 mg given every 2-4 hours. The goal is to get the pt to a 40mg/day maintenance level

Methadone

Naltrexone is not an opioid, it is an opioid antagonist, _____ preventing the user from reaching the euphoric phase, and making the potential for misuse less

blocking the brain’s opioid receptors

Additional meds may be px during the detoxification phase including ___

Benzodiazepines—to reduce anxiety and irritability, Antidepressants—like Prozac or Zoloft to counter depression, Clonidine—reduces sweating, cramps, muscle aches, and anxiety. It can also stop tremors and seizures.

_____ frequently is increased when alcohol and other drugs like stimulants are used; fluctuations can be particularly significant.

blood pressure

_____ of alcohol and of tobacco: Many alcohol users are also heavy tobacco users.

Breath and body odor

constricted pupils when pt is on

heroin, morphine, oxycodone, fentanyl, methadone, codeine, hydrocodone

Dilated pupils when pt is on

Amphetamines, methamphetamine, cocaine or crack, hallucinogens, marijuana

Drugs that are usually prescribed to treat the symptoms of depression and anxiety disorders are often used to treat clients with addictive behavior disorders.

Pharmacologic treatment

Many substance abusers will premedicate with their drug of choice before a dental appointment, questions about substances used and routes of administration should appear on dental office health history forms, recovering addicts may be cautious or anxious about taking any type of mediation, and some may experience a tolerance to sedatives and analgesics, the use of multiple short (20-minute) appointments may be necessary for chemically dependent clients

Dental Hygiene Diagnosis and Care Planning