Oral Manifestations of Commonly Used Chemical Substances

Today, dentists are among the most frequently visited healthcare providers, making it likely they will encounter patients with a history of illicit drug use. Such exposure accentuates a need for dentists to be able to identify oral signs as well as psychological, behavioral, and social elements of substance use. Routine use and addiction to powerful drugs, such as fentanyl and methamphetamine, among dental patients have become more prevalent.

Additionally, today’s drug use and abuse are exacerbated by multiple concomitant factors, such as the use of designer drugs and poly-drugs, which frequently include a combination of street and prescription drugs.

Drugs have deleterious effects on health and cause long-term and permanent disabilities, social problems, drug-related violence, accident-related issues and many overdose-related deaths. While dental problems caused by drug use are not considered life-threatening, they certainly affect the user’s general health.

Adverse oral effects associated with illicit drug use include aggressive caries caused by a high cariogenic diet, bruxism and teeth fractures caused by use of stimulants, progressive periodontal diseases due to exposure to toxic chemical compounds, general neglect, and poor oral hygiene caused by disregard for oral health.^1,2

Cannabis (Marijuana)

Expanding legalization of cannabis for medical and recreational use has certainly allowed dentists to observe the direct effects of cannabis on dental health. Many oral health professionals encounter more patients reporting xerostomia and oral malodor as side effects of marijuana use. While many commonly used prescriptions and over-the-counter medications hinder the normal functioning of salivary glands, marijuana is probably the most common offender.³

The most conventional way of using cannabis is smoking, which is frequently accompanied by tobacco and alcohol use. Cannabis contains the majority of the same carcinogenic agents as tobacco, causing similar respiratory pathologies as tobacco smoking.^4,5 Moreover, widely documented changes to oral soft tissue presented evidence of increased incidence of leukoedema and increased prevalence of candidiasis (caused by Candida Albicans) in cannabis and tobacco smokers compared to nonusers.⁶

Subsequent to xerostomia, cannabis smoking is associated with the development and progression of periodontal diseases, leukoplakia, and erythroplakia of the mucosa, and the development of dysplasia as well as potentially increased risk of developing squamous cell carcinoma in the oral cavity and neck.⁷

According to the American Dental Association, the smoke from cannabis has an immunosuppressive effect on oral soft tissues, leading to a higher number of bacterial colonies and activation of oral candida. Such opportunistic infections, when exacerbated, lead to stomatitis and periodontitis, and can progressively lead to periodontal diseases.⁸

Marijuana users frequently have episodes of acute anxiety that lead to paranoia, which worsens when patients experience stressful events such as a dental visit.⁹ Such acute anxiety episodes are difficult to control in a dental setting, especially when they happen in the middle of the procedure.

Additional consideration arises in relation to dental treatment of intoxicated patients. While cannabis has some sedative effects, in low doses, it is much more stimulating and may cause subsequent tachycardia. The use of adrenaline-containing local anesthetic on intoxicated patients can significantly exacerbate the risk of cannabis-related tachycardia.¹⁰

Alcohol

Alcohol ranks as the most prevalent addictive substance, which leads to more cases of chemical dependence than any other drug. Made from fermented sugars, alcohol is very acidic in nature. To make matters worse, many alcohol preparations involve additions of processed sugars and flavor enhancers that make those preparations even more corrosive.

Repetitive exposure to such strong acidic elements often leads to digestive problems including acid reflux and dental caries caused by the caustic nature of the acids. The degree of alcohol’s effect on the oral cavity directly depends on concentration, acidic properties, frequency, and the volume of alcohol consumption.

Among the most notable and immediate effects of alcohol on the oral environment are xerostomia and direct damage to the oral mucosa. Xerostomia is caused by the fact that alcohol is a strong diuretic, causing the kidneys to produce more urine and increased urine output, which leads to rapid dehydration. Dehydration decreases saliva production, resulting in a dry mouth and subsequent xerostomia.

The combination of acidic conditions and reduced saliva volume only exacerbates the destructive effects of alcohol. Reduction in salivary flow significantly increases the volume of intraoral bacteria that otherwise are naturally removed and/or neutralized by saliva. Such interruption of this natural protective process is one of the main reasons why high alcohol consumption is directly associated with a higher incidence of tooth decay.

Another reason why frequent alcohol use leads to caries is the fact that alcohol metabolizes into sugar, providing nutrition for the bacteria and causing progressive enamel and dentin decay. In addition to red and white wines, beer, and soft drinks, most mixed drinks and cocktails use sugar-based concentrations containing acids, facilitating the damaging erosion of dental enamel. Furthermore, alcohol irritates oral and pharyngeal mucosa, causing reactive inflammation and further reducing saliva production. Chronic alcohol consumption and reduced saliva flow can cause a range of symptoms such as sore throat, thinning of the epithelial layer, and difficulty swallowing, to name a few.

Cocaine and Methamphetamine

Both cocaine and methamphetamine are psychostimulants, which are characterized by increased dopaminergic and noradrenergic neurotransmission in the central nervous system. Methamphetamine is a particularly addictive substance.¹¹

Medical effects of stimulants include hyperactivity, increased alertness, insomnia, hypertension, myocardial ischemia, and tachycardia, leading to myocardial hypertrophy and atrial and ventricular arrhythmias. Psychological effects include paranoia, agitation, mood disturbances, anxiety and violent behavior, and cognitive and mental health changes.¹²

The presence of such symptoms can certainly affect dental treatment. Injection of epinephrine-based local anesthetics can facilitate systemic vasoconstriction and exacerbate tachycardia, hypertension, and ventricular arrhythmias to the levels of uncontrollable cardiovascular events. Mental changes and the possibility of sudden psychotic episodes significantly compromise patient safety during invasive dental treatment and certainly put a question mark on the validity of the patient’s informed consent. These risks become significantly elevated when the dentist fails to recognize the presence of stimulant intoxication prior to treatment initiation.

Dental signs of stimulant use include perhaps the most famous ones like “meth mouth” and frequently infected gingival ulcers caused by vasoconstriction as a result of the direct application of the substance to the gingivae.

More severe complications affecting the patient’s dental health include damage to the maxillary sinuses and palate and occasional perforations causing communications between the oral cavity and maxillary sinuses. Furthermore, poor healing of maxillary extraction sites caused by vascular necrosis and the presence of periodontal diseases caused by chronic vasoconstriction are also oral complications of stimulant use.

These clinical presentations are more prominent among patients who smoke methamphetamine. The thermal effects of smoke significantly multiply its effects. Methamphetamine and crack cocaine are most frequently smoked with pipes that result in a direct application of heated acidic drugs to the teeth and soft tissue surfaces. This practice, in addition to significant sugar cravings (especially for sugary, acidic sodas), directly links stimulant usage to rampant caries of catastrophic proportions. Rampant caries is also aggravated by a reduction in salivary flow and a reduced buffering ability of salivary volume.¹³ Lastly, stimulants are directly related to significant clenching and grinding associated with temporomandibular joint disorders, fractured teeth, and gingival recession caused by bruxism.

Opioids

Opioids act on opioid receptors of the central and peripheral nervous system to produce morphine-like effects. Opioids act as agonists on mu, delta, and kappa receptors, causing analgesia, euphoria, sedation, respiratory depression, nausea, and constipation.

Opioids include legally prescribed codeine, hydrocodone, oxycodone, morphine, and other formulations of opioid painkillers. Opioids also include illegal drugs such as heroin and synthetic opioids like fentanyl. Today, opioids contribute to the highest mortality and morbidity correlated with illicit drug use and abuse in the world, creating an unprecedented public health crisis.

The use and abuse of opioids are linked to severe dental problems. The main side effects include tooth decay caused by intense cravings for sweet foods and subsequent xerostomia. Additionally, opioid use may lead to severe anxiety and cravings that cause bruxism and grinding, resulting in wear down and fractures of dental enamel. Destructive characteristics of opioid use include progressive periodontitis, presence of oral fungus, and oral viral infections. A significant portion of these oral complications are attributed to the abandonment of self-care associated with rapidly developing addiction.¹⁴

Dental treatment considerations relate to metabolic changes caused by opioid use. These include increased risk of infective endocarditis associated with intravenous drug use, reduction of effectiveness of local anesthetics associated with opioid use, and increased anxiety of opioid users.¹⁵ Medical side effects of opioids include infective endocarditis, hepatitis, human immunodeficiency virus, and vascular necrosis frequently caused by adulterants used to dilute pure heroin, such as quinine, lactose, or powdered milk.

Illicit opioids are administered orally, nasally, and injected intravenously or subcutaneously. The highest risk of opioids is associated with unintentional overdose, bloodborne virus transmission, and opioid use-associated crime.¹⁵

Opioid addiction treatment is a long-term process that causes overwhelming cravings in the user. Methadone, a synthetic opioid, is used to prevent withdrawal symptoms and relapse while not producing the euphoric effects elicited by opioids. It is not unusual for dental providers to treat patients enrolled in long-term medication-assisted recovery or methadone maintenance programs. Dental management of such patients, as well as patients with a history of opioid use disorders, certainly limits dentists’ options when it comes to post-operative pain management. Prescriptions for opioid-based painkillers, as well as benzodiazepines, must be excluded or reduced to a bare minimum and preferably coordinated with primary care providers who may help to direct post-operative pain management to reduce the chance of relapse.

Benzodiazepines

Benzodiazepines are sedative hypnotic medications. Unlike opioids, which take weeks to develop a strong dependence, dependence on benzodiazepines develops over a few months. Dependence, however, is not the same as addiction and needs to be examined from the point of view of synergistic actions of co-prescribed opioids and benzodiazepines.

Co-prescribed opioids and benzodiazepines increase the risk of overdose because both types of drugs can cause sedation and suppress breathing. Furthermore, in addition to impaired cognitive function, co-prescribing benzodiazepines and opioids can significantly increase the risk of overdose fatality.¹⁶

Clinicians must understand that the half-life and elimination time of some benzodiazepines are notably long. For example, short-acting benzodiazepines have a median elimination half-life of 1 to 12 hours, intermediate-acting have an average elimination half-life of 12 to 40 hours, and long-acting have an average elimination half-life of 40 to 250 hours.¹⁷ Prescribing opioid-based pain killers to be taken within 1 to 2 hours after dental procedure to patients who took benzodiazepine for preprocedure anxiety relief will invertedly lead to post-procedural drug overdose and respiratory suppression. This is especially risky in elderly and pediatric patients as well as patients with reduced respiratory functions such as chronic obstructive pulmonary disease or pulmonary fibrosis.

Such potential clinical complications certainly warrant diligent examination of the patient’s medical history with special emphasis on prescription medications and recreational drug use to avoid accidental and potentially fatal overdose.

Special attention should also be paid during the administration of nitrous oxide to patients after the administration of anxiolytic benzodiazepines due to the reduced supply of oxygen to the body. In 2022, the United States Centers for Disease Control and Prevention issued a Clinical Practice Guideline for Prescribing Opioids for Pain that provides recommendations for clinicians providing pain care and prescribing opioids. It is an excellent resource for all medical practitioners to help clinicians adjust their prescribing practices to reflect modern medical standards.¹⁸

Conclusion

For many people who do not visit medical care providers unless there is an emergency need, a visit to the dentist frequently represents the only interaction with a healthcare provider. Such reality stresses the significance of the dental encounter as an essential opportunity to screen for and identify substance misuse. An awareness of the prevalence and familiarity with oral manifestations of substance use and abuse are essential for modern dental care providers. Moreover, the knowledge and understanding of addiction are essential for any practicing clinician.

References

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2. Center for Behavioral Health Statistics and Quality. Results from the 2015 National Survey on Drug Use and Health. Available at: samhsa.gov/​data/​sites/​default/​files/​NSDUH-DetTabs-2015/​NSDUH-DetTabs-2015/​NSDUH-DetTabs-2015.pdf. Accessed August 8, 2024.
3. National Institute of Dental and Craniofacial Research. Dry Mouth. Available at: nidcr.nih.gov/​health-info/​dry-mouth. Accessed August 8, 2024.
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8. American Dental Association. Cannabis: Oral Health Effects. Available at: ada.org/​resources/​research/​science-and-research-institute/​oral-health-topics/​cannabis-oral-health-effects. Accessed August 8, 2024.
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12. Teoh L, Moses G, McCullough MJ. Oral manifestations of illicit drug use. Aust Dent J. 2019;64:213-222.
13. Teoh L, Moses G, McCullough MJ. Oral manifestations of illicit drug use. Aust Dent J. 2019;64:213-222.
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15. Titsas A, Ferguson MM. Impact of opioid use on dentistry. Aust Dent J. 2002;47:94–98.
16. Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996-2013. Am J Public Health. 2016;106:686-688.
17. Griffin CE 3rd, Kaye AM, Bueno FR, Kaye AD. Benzodiazepine pharmacology and central nervous system-mediated effects. Ochsner J. 2013;13:214-223.
18. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71:1-95.

From Decisions in Dentistry. August/September 2024; 10(5):32-35