When treating a drug user, a dentist’s duty of care can be difficult to negotiate, embarrassing for the patient and uncomfortable to discuss. But it’s not impossible. By Frank Leggett
Patients who use illicit substances come from a wide range of ages, occupations, sexual preferences and ethnicities. One of the few things they have in common is that their substance use and associated lifestyle has a negative impact on their general and oral health.
While a dentist has a clear duty of care in regard to their patients and a responsibility to provide safe and effective dental care, how far does that extend when dealing with a substance user? Is it prudent to question patients about their lifestyle choices? As a medical professional, are they within their right to offer advice to their patient?
Dr Hooman Baghaie has been looking at these very questions. To better understand the links between oral health and general health, this Queensland dentist is completing his medical training and is in his third year of medicine at Griffith University. Dr Baghaie has authored multiple research papers on substance abuse and oral health and has presented at multiple conferences.
“From a dental perspective, some clues that a patient may be a drug user are the presence of opportunistic infections like candidiasis, as well as caries, periodontitis and non-carious tooth loss that’s grossly out of proportion with the patient’s known risk factors,” says Dr Baghaie. “However, there are plenty of other reasons why a patient may be present with any of these findings. You won’t know unless you ask.”
Of course, this can be a tricky subject to broach. A little care and preparation needs to be taken before delving into a patient’s lifestyle choices.
“It is important to stay present and non-judgmental to maintain professionalism and facilitate an open discussion. Given the sensitive information, there’s no room for acting shocked or surprised.”
Dr Hooman Baghaie, dentist
“It’s important to take the time to actively listen to all patients and to show you are interested in helping them,” says Dr Baghaie. “When taking their history, we ask about habits in regard to brushing, flossing, diet, smoking and alcohol. The next natural step is to ask about substance use. It is important to stay present and non-judgmental to maintain professionalism and facilitate an open discussion. Given the sensitive information, there’s no room for acting shocked or surprised. Another option is to explain what you’re going to ask and why. It can be something along the lines of ‘another risk factor for dental caries is substance use, so we are going to talk about it next’.”
Prevention is key
Preventive care is the cornerstone of dentistry. It’s the dentist’s job to promote patients’ oral health through a mix of education, prevention and rehabilitation. Patients with substance use are no different.
“Substance-users just present with more delicate challenges that we must professionally and empathetically circumnavigate,” says Dr Baghaie. “For instance, motivational interviewing can be adapted to assist in the reduction of substance use. Additionally, we may consider more frequent recalls or optimisation of fluoride exposure.”
That being said, GPs are well versed with the services available for people struggling with substance use. Having discussed the negative effects of substance abuse on teeth with the patient, the dentist can encourage them to speak to their GP for further support, and to link them to a range of services.
Drug users can also have associated lifestyle problems that sometimes lead to an increase in the number of sexual partners. This, in turn, can present an increased risk of sexually transmitted infections with various implications to oral and general health.
Dr Beata Rumianek runs her own dental practice in Ashfield, NSW, and has a master’s degree in sexual health. She has seen an increase in the rate of human papilloma virus infection (HPV) and oropharyngeal cancer. And there is a direct link between the two.
“After an extraction, or any surgery in the mouth, I would like to see dentists get a little more proactive. Among the after-care instructions they should also add, ‘No oral sex for the next two weeks’.”
Dr Beata Rumianek, dentist
“There are two types of oropharyngeal cancers,” says Dr Rumianek. “One is due to smoking, and the prevalence of this type is decreasing. However, the prevalence of oropharyngeal cancer due to HPV is increasing. The determining factors are the lifetime number of sexual partners and the age of initiating sexual activity. Engaging in oral sex is a major determining factor.”
Any dentist suspecting that a patient has HPV should immediately refer them to a specialist. While most cases are usually benign, about 10 to 20 per cent of cases turn into cancer over time.
“After an extraction, or any surgery in the mouth, I would like to see dentists get a little more proactive,” says Dr Rumianek. “Among the after-care instructions they should also add, ‘No oral sex for the next two weeks’. When there is an open wound in the mouth, all sorts of viral infections can enter.”
One last thing to remember when dealing with illicit substance users is the issue of capacity and consent. For a person to give consent, they need to have capacity.
“If you suspect that a patient is under the influence of alcohol, narcotics or other substances, they may lack the capacity to consent to treatment,” says Dr Baghaie. “Unless there is a medical emergency, informed consent is required for treatment. In such situations, it would be wise to postpone treatment and reschedule until the patient is back to their sound mind and able to make decisions.”
Discussions of drug use, oral sex and lifestyle choices can be a bit of a minefield for a dentist to navigate but by staying professional, non-judgmental, unprejudiced and empathetic, it’s possible to fulfil the duty of care.