Interview: “Oral health should not be looked at in isolation”
Whether or not to provide dental treatment for patients with drug dependencies can be a difficult decision for dentists to make. Dental Tribune International spoke with Dr Charlotte Bowes, Clinical Fellow in Restorative Dentistry at Newcastle University’s School of Dental Sciences and co-author of a recent article in the British Dental Journal on this topic, about the current guidance in the UK regarding this issue, the existing barriers to treatment and what she thinks could be improved.
Dr Bowes, with what dental conditions are the various forms of drug dependency associated?
People with drug dependencies commonly suffer from caries, periodontal disease, mucosal dysplasia and tooth surface loss. Opioids, including cocaine, heroin and methadone, can have a xerostomic effect that can increase incidence of caries. Opioids, additionally, have an analgesic effect, which can prolong dental problems owing to the lack of awareness of pain. Bruxism can also often be a side effect of drug withdrawal and this can lead to tooth surface loss.
Oral health problems can also be caused by concomitant use of alcohol and tobacco by people with drug dependencies. It is well known that smoking and increased alcohol use are risk factors for oral cancer. Unfortunately, there seems to be a dearth of evidence differentiating between specific drugs and their oral health problems.
Is there a current protocol for providing dental treatment to patients with drug dependencies in the UK?
There is limited information for dentists in the UK about treating patients with drug dependencies. As an NHS dentist in England myself, it can often feel like a “suck-it-and-see” approach. In online searches, I found that the Welsh government published a document in 2013 that included oral health recommendations. Although it is admirable that oral health features in this document, it is far from being a protocol.
Recommendations for provision of dental treatment for people with drug dependency are mainly prevention-based, such as dietary advice and oral health education. Although prevention is important, other issues can be left unaddressed; for example, how does a primary care dentist manage a patient with active drug dependency attending in pain? There are issues surrounding pharmacological interactions, such as possible inability to achieve anaesthesia owing to a higher pain threshold, and concerns surrounding ability to consent. The framework, however, does acknowledge that an outreach service would be beneficial, yet patients need to ask for domiciliary services themselves or be referred to a community dental setting, requiring an initial high-street dentist appointment.
In stark contrast, the Department of Health has published guidelines that outline clinical management, including psychosocial, pharmacological and specific treatment situations of people with drug dependency, yet there is no mention of dental or oral care. This is despite the multitude of oral problems associated with drug dependency.
What are the main barriers to these patients receiving treatment?
- They include anxiety, stemming from a fear of dentists, fear of judgement by the dentist or other patients, or a fear of needles;
- embarrassment, resulting from an awareness that they have caused their own dental problems;
- cost issues (though sometimes this can be a misconception of the cost of dental treatment: having talked to people with substance dependency, I find that they are often unaware of the cost of NHS dental treatment or their possible exemption entitlement);
- lack of access, owing to lack of NHS dentists in the area;
- being deregistered, owing to poor attendance through dependency, and consequent need to find another dentist;
- reluctance of NHS dentists to take on new, high-risk patients who may require a lot of dental work—the 2006 dental contract does not remunerate dentists for large amounts of work carried out in one course of treatment; and
- dentists may be fearful of potential blood-borne viruses in people with drug dependency.
How do you envision a successful service model for patients who misuse substances?
From my experience as a dentist and having talked to people with drug dependency, dental care should be available as part of a drug dependency service. Dental health is seen as an outlier to the medical profession; however, it should be an integral part of it. Oral health should not be looked at in isolation; a holistic approach to people with drug dependency will improve general and oral health and can also have an impact socially.
Improving oral health in people with drug dependency can help with social reintegration, as health and aesthetic improvement can reduce the stigmatisation associated with drug abuse. For example, “meth mouth”, a common phenomenon, signifies frank caries affecting the dentition and is visually obvious. This can cause embarrassment when attending dental appointments or job interviews and could hinder recovery from drug addiction, as it becomes difficult to move forward in life.
I feel that conventional high-street NHS dentistry is not a suitable modality for the provision of dental treatment for people with drug dependency. Owing to the perceived and actual barriers to NHS dentistry, it would be more appropriate for dental care to be integrated with substance addiction services. Commissioning via NHS England would have to occur, which would require further research into the prevalence of oral health problems among this cohort. This would ascertain how widespread the problem is and highlight the benefits of a specific service. I envisage a service where dentists conduct outreach to drug dependency centres and/or are based within a recovery centre and regarded as valued members of the team. Dentists would need to be salaried, since the current remuneration system, as discussed earlier, is just not suitable for providing therapy to this cohort.
Editorial note: Dr Bowes' article, titled "The need for further oral health research surrounding the provision of dental treatment for people with drug dependency", was published online in the British Dental Journal on July 12, 2019.