Page 2

Quality Resource Guide –

Management of the Substance Use Disorder Dental Patient 1st Edition

www.metdental.com

oral hygiene, poor dietary habits, and failure

to maintain routine dental visits.

Xerostomia

and its resultant impact on the hard and soft

tissues of the oral cavity are the most

significant

oral manifestations.

Rapid decimation of the

dentition, soft tissues complications, associated

discomfort and complications in reconstructing

lost oral function are formidable challenges to

the dentist when managing a patient affected by

substance use.

Table 3 outlines the most common

oral manifestations, their causes and associated

substances.

8,17-24

The recognition of these

pathognomonic oral manifestations, combined with

the patient’s history and observed behaviors can

lead to early intervention strategies by the dentist,

including potential referral for medical treatment.

Dental Treatment

Dentists should be aware of some key

pharmacologic considerations when using local

anesthetics, analgesics, and antibiotics in treating

the SUD patient.

Local anesthetics and intravenous sedation

Due to the development of cross-tolerance from

prior exposure to similar drugs, the SUD patient

may experience a diminished response to local

anesthetics

7,25,26

and may need additional local

anesthetic during a dental procedure to achieve

pain control. The maximum safe dose of the

local anesthetic agent administered remains

unchanged.

Patients who have a history of

or who are currently using a stimulant such as

cocaine, amphetamine, or methamphetamine are

at increased risk of acute cardiovascular events:

severe hypertension and cardiac arrhythmia.

27,28

A local anesthetic without epinephrine should be

selected to prevent potential sympathomimetic

stimulation in these patients.

27,29

Mepivacaine 3%

without a vasoconstrictor causes less vasodilation

than lidocaine and is a good alternative.

Mood-altering drugs such as benzodiazepines

and nitrous oxide may increase the tendency for

further drug abuse by creating similar pleasurable

sensations in the SUD patient.

8,27-29

When SUD

patients require sedation with benzodiazepines

or nitrous oxide, they should be referred to

practitioners with experience with these patients.

Patients with significant abuse histories who need

extensive dental interventions may be considered

for care in the operating room environment.

Table 1 - Diagnostic Criteria for Substance-Use Disorder Substance Use Disorder*

1. Substance is often taken in larger amounts or over a longer period than intended.

2. A persistent desire or unsuccessful effort to cut down or regulate substance use - may report multiple unsuccessful efforts to decrease or

discontinue substance use.

3. A great deal of time is spent in activities necessary to obtain substance, use the substance, or recover from its effects.

4. A craving for the substance, or a strong desire or urge to use substance.

5. Recurrent substance use resulting in a failure to fulﬁll major role obligations at work, school, or home (repeated absences or poor work perfor-

mance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).

6. Continued substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by effects of the substance

(arguments with spouse about consequences of intoxication, physical ﬁghts).

7. Important social, occupational, or recreational activities are given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous (driving an automobile or operating a machine when impaired).

9. Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been

caused or exacerbated by the substance.

10. Tolerance is present - deﬁned by either or both of the following:

• A need for markedly increased amounts of substance to achieve intoxication or desired effect.

• Markedly diminished effect with continued use of the same amount of the substance.

(

Note:

Criterion #10 is not considered to be met for individuals taking a prescribed medication such as analgesics, antidepressants, anti-anxiety medication, or beta-blockers

under appropriate medical supervision)

11. Withdrawal is present - manifested by either of the following:

• A characteristic substance withdrawal syndrome.

• Substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

(

Note:

Criterion #11 is not considered to be met for individuals taking prescribed medication such as analgesics, antidepressants, anti-anxiety medication, or beta-blockers

under appropriate medical supervision)

0 to 1

criterion present

no diagnosis

2 to 3

criterion present

mild substance use disorder

4 to 5

criterion present

moderate substance use disorder

6 or more

criterion present

severe substance use disorder

* Adapted from Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition