Substance-Related Disorders – Dental Hygiene Lecture

Overview of Substance-Related Disorders

• Substance addiction = chronic, excessive use of drugs/alcohol → brain dopamine surge + endorphin release.
• Universally cross-cuts age, gender, socioeconomic status, education.
• Multifactorial etiology: genetic predisposition, environmental exposure, psychological stressors, social influences.

Alcohol-Specific Concepts

Legal & Measurement Benchmarks

• Standard drink defined to yield Blood-Alcohol Concentration (BAC).
• Legal intoxication in most U.S. jurisdictions: 0.08\%\;\text{g/dL}.

Clinical Patterns

• Frequent, heavy, or binge drinking.
• Loss of control; use despite harm.
• Two archetypes:
– Daily low-grade intake.
– Episodic binge (>4 drinks/occasion women; >5 men).
• Tolerance = need for escalating doses to reproduce prior effect.

Overdose (Acute Toxicity)

• Key signs: vomiting, confusion, bradypnea (

Metabolism & Pharmacokinetics

• Absorption: stomach + small intestine → portal circulation.
• Hepatic conversion: Ethanol (\xrightarrow{ADH}) acetaldehyde (\xrightarrow{ALDH}) acetate (\rightarrow) \text{acetyl-CoA}.
• Zero-order kinetics: liver clears ≈ 1 drink/hour ≈ 0.015\% BAC/hr (largely independent of gender, body size).
• Modifying factors: genetics, hepatic disease, medication (e.g., acetaminophen), food intake.

Systemic Health Hazards

• CNS: depressant, impaired cognition, memory deficits.
• Cardiovascular: hypertension, cardiomyopathy, arrhythmias.
• Hepatic: fatty liver → hepatitis → cirrhosis.
• GI: gastritis, pancreatitis.
• Cancer risk ↑ (oropharynx, esophagus, liver, breast, colorectal).
• Immunity ↓, reproductive dysfunction.

Oral Health Implications

• Delayed wound healing, ↑ infection.
• Xerostomia → caries, mucosal irritation.
• Synergistic oral squamous-cell carcinoma risk with tobacco.
• Alcoholic diet high in fermentable carbohydrates → caries, periodontal disease.

Fetal Alcohol Spectrum Disorders (FASDs)

• Ethanol freely crosses placenta → fetal BAC ≈ maternal BAC.
• Outcomes: spontaneous abortion, stillbirth, growth retardation, CNS malformation.
• Classic facial phenotype: short palpebral fissures, smooth philtrum, thin upper lip.
• Lifelong physical, cognitive, behavioral disabilities.

Alcohol Withdrawal Syndrome (AWS)

• Mild (within 6 h): insomnia, anxiety, nausea, tremor, ↑ BP.
• Moderate ( 12!–!24 h): tactile/auditory hallucinations, seizures.
• Severe – Delirium Tremens (DTs) ( 48!–!72 h): confusion, autonomic hyperactivity, mortality 5\%!\text{–}!15\% without treatment.

Treatment of Alcohol Use Disorder (AUD)

• Screening: CAGE, AUDIT-C, TAPS.
• Behavioral: CBT, motivational interviewing, family therapy.
• Pharmacologic:
– Naltrexone (ReVia) ↓ reward.
– Acamprosate (Campral) ↓ craving.
– Disulfiram (Antabuse) aversive; alcohol contraindicated within 12 h & up to 2 wk post-dose.
– AWS management: benzodiazepines, anticonvulsants, baclofen, \gamma-hydroxybutyrate, psychotropic analgesic nitrous oxide (PAN).
• Mutual support: Alcoholics Anonymous (AA), 12-step.
• Settings: outpatient, partial hospitalization, inpatient residential.

Non-Alcohol Substance Abuse

Epidemiologic Context

• Legal cannabis expansion + opioid epidemic ⇒ every dental practice encounters chemical dependency.
• Screening tool: Drug Abuse Screening Test-10 (DAST-10); NIDA provides chairside questionnaires.

Commonly Abused Drugs & Oral Sequelae

• Depressants – Alcohol → xerostomia, cancer.
• Stimulants – Cocaine ("coke, crack") → mucosal ulceration, bruxism, palatal perforation.
• Stimulants – Methamphetamine ("meth, ice") → "meth mouth": rampant cervical caries, xerostomia, attrition, trismus.
• Hallucinogens – LSD, psilocybin → oral trauma risk, xerostomia, bruxism.
• Opioids – Heroin, oxycodone → dry mouth, infection risk.
• Cannabis – Marijuana → xerostomia, periodontal disease, increased caries.

Systemic Medical Effects

• Cardiovascular, neurologic, GI, renal, hepatic, respiratory compromise.
• Prenatal exposure → teratogenicity.
• Infection vectors: HIV, hepatitis B/C from injection.

Dental Hygiene Process of Care (DHPC)

Assessment

• Comprehensive health history; include substance use subsection.
• Vital signs—note hypertension (e.g., 205/110\,\text{mmHg} case example).
• Extra-Oral findings: jaundice, urticaria, pruritus, granulomas, flushing, premature aging, needle-track covering (long sleeves), cachexia.
• Head & neck cancer risk ↑ with smoked/vaped substances.

Intra-Oral Findings

• Meth: rampant caries, severe xerostomia, bruxism, cracked teeth, periodontal destruction.
• Cocaine: palatal/nasal septum perforation, facial deformity, xerostomia, erosive caries, gingival necrosis, ageusia.
• Hallucinogens: xerostomia, TMJ pain, bruxism, lichenoid lesions.
• Cannabis: leukoedema, stomatitis, glossitis, angular cheilitis, burns from hot smoke.
• Universal: parotid swelling, severe periodontitis, attrition/erosion, poor hygiene, cariogenic diet.

Risk Management & Prescription Control

• Dental team must curb opioid over-prescription; utilize Prescription Drug Monitoring Programs (PDMP).
• Avoid paper Rx pads; e-prescribe to limit diversion.
• Educate patients on storage & disposal.
• Ongoing CE for providers on substance use.

Emergency Preparedness

• Naloxone (Narcan/Evzio) – opioid antagonist; OTC in U.S./Canada; onset minutes; include in emergency kit; anticipate acute withdrawal symptoms post-administration.

Documentation Standards

• Flag chart in medical alert box: alcohol-free mouth rinse, avoid vasoconstrictor (epinephrine) if cocaine within 24 h, etc.
• Meticulously record: unusual caries pattern, rapid periodontal changes, ulcerations, behavioral issues.
• Sample SOAP note provided (Box 59-4) demonstrating refusal of care due to hypertensive crisis & patient exit.

Patient Education Strategies

• Explain specific oral/systemic effects of their substance use.
• Promote regular professional maintenance + meticulous daily biofilm control.
• Recommend diet modification to reduce cariogenic exposure; stress nutrition for tissue healing.
• Caries prevention: topical/systemic fluoride, chlorhexidine rinses (alcohol-free).
• Counsel on pregnancy risks of alcohol/illicit drugs.
• Use motivational interviewing: open questions, affirmations, reflective listening, summaries (OARS).

Ethical, Legal & Interprofessional Considerations

• Duty to treat without discrimination yet maintain clinician safety.
• Confidentiality vs legal reporting obligations (e.g., impaired driving, child endangerment).
• Collaborate with physicians, addiction specialists, mental-health providers for comprehensive care & referral.
• Follow state dental practice acts regarding controlled substances & naloxone administration.

High-Yield Numerical & Formula Summary

• Legal BAC: 0.08\%\,\text{g/dL}.
• Hepatic clearance: 1 drink ≈ 0.015\% BAC/hr.
• AWS timeline: mild <6 h; seizures 12!–!24 h; DTs 48!–!72 h.
• Disulfiram–ethanol interaction window: avoid alcohol \le12 h before & \le2 wk after dose.

Practical Takeaways for Exams & Clinic

• Recognize substance-related oral patterns (meth mouth, palatal perforation) on boards/OSCEs.
• Always take thorough social & medication history; validate with screening tools.
• For hypertensive or intoxicated patients postpone elective procedures, refer for medical clearance.
• Never administer local anesthesia with epinephrine in suspected recent cocaine users (↑ arrhythmia risk).
• Keep Narcan accessible; know intranasal vs intramuscular dosing protocols.
• Integrate brief intervention (SBIRT) into routine hygiene appointments.