Quality Resource Guide l Management of the Substance Use Disorder Dental Patient 3rd Edition 4 www.metdental.com 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. 11,31,32 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. 33 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. 33,34 A local anesthetic without epinephrine should be selected to prevent potential sympathomimetic stimulation in these patients. 34,35 Mepivacaine 3% without a vasoconstrictor causes less vasodilation than lidocaine and is a good alternative. 33 In the event a local anesthetic cannot be used or the patient does not tolerate traditional dental care, the use of silver diamine fluoride 30 may be considered for noninvasive treatment of caries along with the use of atraumatic restorative techniques. 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. 12,33-35 Further, there appears increased risk of overdose and death when benzodiazepine and opioids are used in combination. 36 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 3 - Oral manifestations in substance abuse 12,21-30 induced by direct drug effects, neglected oral hygiene, poor dietary habits, impeded access to care Oral Condition Cause Linked Substances • Xerostomia • Thinning of oral mucosa Anticholineric induced hypo-salivation For all Conditions • Methamphetamine and other stimulants • Opiates • Barbiturates, • Dissociative drugs (PCP) • Hallucinogens (LSD) • Marijuana and cannabinoids like hashish • Club drugs (GHBO) • Alcohol • Tobacco Oral manifestations are more pronounced in patients abusing multiple substances • Dental caries - most notably along facial and cervical areas (rapidly progressing) Xerostomia and decreased salivary pH; sugar craving behavior evidenced by consumption of non-diet carbonated beverages; neglected oral hygiene • Attrition and erosion • Dental hypersensitivity Acidic substances used in illicit drug production; decreased salivary pH; sugar craving behavior evidenced by consumption of non-diet carbonated beverages; bruxism stemming from direct effect of drug (increase in motor activity) or restlessness secondary to psychological disorders like depression • Mechanical soft tissue injury • Morsicatio buccarum, linguarum and labiorum • Frictional keratosis • Traumatic ulcerations or lacerations Increased motor activity and restlessness combined with mucosal thinning secondary to xerostomic conditions; psychological disorders. • Soft tissue changes – angular cheilitis, glossitis, jaundice, leukoplakia, leukoedema, candidiasis and rhinitis Depressed immune system; liver damage • Atropic tongue, glossodynia, angular cheilitis Vitamin B12 deficiency • Parotid enlargement Inflammatory infiltrate • Periodontitis Neglected oral hygiene Recognition of 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