Dental problems in addiction treatment subjects. Does methadone rot teeth? Can we prevent dental decay?

Tues 20 May 2003

Presenter:
Dr Peter Foltyn (Dentist, St Vincent's Hospital)

Main speaker Dr Peter Foltyn (Dentist, St Vincent's Hospital). Chaired by Dr Richard Hallinan who gave several amusing anecdotes from his father who is a retired dentist.

Dr Hallinan began by reminding us how much a smile is worth at a job interview as well as the draw backs of bad breath and poor nutrition which are so common in dependency cases. He invited the large audience (of over 40) to benefit from Dr Foltyn's 20 year experience in treating such patients in his practice at Darlinghurst, Sydney.

Dr Foltyn gave us all a timely reminder of the importance of good dental care and the pitfalls of a number of factors countering dental hygiene. He dealt with a number of important issues for patients with drug and alcohol problems including xerostomia (dry mouth). When the salivary mechanism is inhibited there is a break-down of the normal manner of diluting and removing debris resulting in a lower pH and an acidic environment for the teeth. This allows penetration of the enamel, especially at the gingival margins where it is thinnest and where is joins the dentine. Thus for patients who are taking antidepressants, anti-cholinergics and for some patients on methadone there is a need to counter dry mouth. The use of 'swish and rinse' at the time of medication (and at other times during the day and night) can be very effective in protecting the teeth. Chewing gum can stimulate salivation and sugar-free gums are now available.

Regular brushing after each meal, however, is still the mainstay of treatment/prevention. We were told that a medium brush with small, angled head is best and that much modern tooth paste is either unnecessary and in some cases may cause irritation to already delicate buccal surfaces. This, we were told, was largely due to the foaming agent used in virtually all proprietary brands available in supermarkets. Sodium laurel sulfate has been shown to increase irritation in some people but there are only two current brands available (largely at chemist shops) which omit the use of this chemical. The other agents common to most tooth pastes are an abrasive agent as well as a detergent. It may be that brushing with just water is as effective and less irritating to some people than when using some pastes. We were told that while some electric tooth brushes have certain advantages, they are not necessary for optimal dental care.

Another common cause of xerostomia in the hospital setting is head and neck radiotherapy. It can be so devastating for the teeth that occasionally extractions are recommended before radiation starts since healing is often so protracted afterwards. Also, infections can set in, including one type of osteomyelitis which is almost untreatable.

We were shown some shocking technicolour anatomy-atlas-type dental soft-porn to demonstrate these matters. Once getting over the initial shock of close-up dental views we then looked at projections of sequential Xrays of dentition in various states of dissolution (literally). Some were in AIDS cases, others nutritional deficiencies, radiation stomatitis and cancer cases, including Kaposi's sarcoma.

Plaque was discussed at length, as well as the various ways of dealing with it. It was pointed out that in some cases plaque can extend under the gingival margins, requiring tooled removal by the dental surgeon. Other exposed areas were dealt with and we were reminded about individual brushing, tooth by tooth on the three surfaces, lingual, buccal and interfacial. Gentle but purposive brushing to engage the gingival margin was stressed. Minor bleeding in inflamed areas is to be expected for a time but continued bleeding should always be examined by the dentist. Flossing to clean the inter-dental surfaces should also be done regularly. Three times yearly check-ups in patients at increased risk was also stressed.

Topical fluoride should be applied in such high-risk individuals and the dental fluoride 'tray' is the most effective way. It is like a mouth guard which should be smeared with fluoride paste/gel and inserted for ten minutes before retiring. Dr Foltyn said that dentists will apply the same thing for a fee, but to do it oneself regularly is more appropriate for most of our patients. It would appear that fluoride can be effective even in late stage dental wear and tear.

We were advised to tell our patients with poor dentition to avoid strong mouth washes with alcohol bases such as Listerine. A water based mouth wash with antiseptic is more appropriate and less likely to cause irritation. Chemists can advise on the types.

The methadone 'syrup' marketed in Australia still contains sorbitol which is a sugar. Although it is not actively absorbed and is safe for diabetics, as a sugar it is still a fuel for oral bacteria and alcohol with other constituents are not likely to help dental hygiene. The sugar-free 'solution' Biodone should probably be our 'first line' product and the 'syrup' mainly used for those sensitive patients who are unable to tolerate the pure medicine. But importantly, Dr Foltyn says that this must not give any false sense of dental security as xerostomia will occur to the same degree with both products.

The use of buprenorphine may also cause dental problems although one would hope to a lesser degree than oral methadone syrup. We need to watch carefully with this new medication and advise regular dental check-ups.

There are many other issues which had to be left to another session and there was lively discussion on this pressing issue. We need to examine better analgesia during and after dental surgery in dependency patients. Antibiotics in those with heart murmurs, prosthetic joints, etc need to be addressed. Putting more resources into high risk cases should be a public health priority as good teeth can improve self confidence, job prospects and even romance!

Dr Foltyn can be contacted for more information. He can send email copies of the excellent hand-out for dental recommendations in xerostomia (dry mouth) as well as the grizzly photographs. He requests that you place "Concord Seminar" in the title. pfoltyn@stvincents.com.au

References:

Sheridan J, Aggleton M, Carson T. Dental health and access to dental treatment: a comparison of drug users and non-drug users attending community pharmacies. British Dental Journal (2001) 191:453-457

Byrne AJ. Methadone and oral hygiene. Australian Dental Journal. 1996 41;1:61

comments and lecture summary by Andrew Byrne ..

Can you compare cannabis with tobacco? BMJ editorial speculates.

'Comparing cannabis with tobacco'. Henry JA, Oldfield WLG, Kon OM. BMJ (2003) 326: 942-943

I would commend these authors on using the correct scientific term cannabis, unlike some colleagues who seem to prefer terms allegedly introduced by governments rather than scientists.

That said, this is one of the most un-scientific BMJ articles I have read. Despite their being opposites in most respects, Henry and co-authors try to compare cannabis and tobacco. While both are common psychoactive drugs, cannabis is a relaxant, tobacco a partial-stimulant. One is highly addicting, the other is not. One has been prescribed by physicians down the ages and continues to be recommended in certain clinical circumstances by doctors of good repute. Hence a 'comparison' is an intriguing concept unless clearly stated objectives are being examined (eg. dependency, mortality, side effects, beneficial effects, etc).

Cannabis has an extremely low mortality while tobacco's toll is legion. Nearly 20,000 Australians die from tobacco related disease each year with few if any cannabis reported deaths.

When examining any drug, one looks for costs and benefits but these authors have only looked for 'costs' and, for cannabis, then they can only point to 'associations'. Even if cannabis actually caused some cases of mental disease (and it does induce dependency in a small proportion of heavy users), the drug may also alleviate some conditions such as anxiety, insomnia, depression, anorexia or chronic pains.

These authors state that it might be seen as 'scaremongering' to speculate on the basis of cannabis being of equal toxicity as tobacco ... yet they go ahead and do just that: "the corresponding figure for deaths among 3.2 million cannabis smokers would be 30,000" [annually in the UK]. Can these authors be serious when no group of suspected cases is yet to be reported after the drug has been used for thousands of years in western society? If they are interested in speculation, why don't they look at alcohol consumption in cannabis smokers?

Quite apart from their tenuous position in trying to point to cardiovascular complications which may occur with smoking cannabis, they make numerous questionable and unreferenced statements in their paper including the howler about cannabis strength increasing over the years (by 10 to 20 times!). Even if this were true, it would mean less by-products for the same amount of drug and thus possibly safer smoking. Also, cannabis can be taken orally with no effect on the lungs at all, but these authors do not canvass that issue, nor other harm reduction steps. Without references, they also quote "Nederweed" ('the variety smoked in the Netherlands') which they claim has an *average* of 10-11% tetrahydrocannabinol. This is obviously unhelpful since Holland, like other countries, has a variety of cannabis and resins available on the market, including cannabis cookies.

These authors make much of the increase in cannabis use and the reductions in tobacco consumption in recent years. However, they are not open enough to discuss the legal status of the drugs. If these authors are honestly concerned about harms from cannabis then it is hard to understand why they would ignore the spectacular failing of current prohibitions in addressing these harms. The results of long term cannabis decriminalization (eg. South Australia, Holland) are equally ignored by these 'scaremongers' (to use their own term).

comments by Andrew Byrne ..

http://bmj.com/cgi/content/full/326/7396/942

More psychosocial services improve outcomes. No surprise.

The Role of Wrap Around Services in Retention and Outcome in Substance Abuse Treatment: Finding From the Wrap Around Service Impact Study. Pringle JL, Edmondston LA et al. Addictive Disorders and Their Treatment (2002) 1;4:109-118

Dear Colleagues,

This lead article had the promise to describe one of the most useful studies since McLellan and Woody's work a decade ago on psychosocial supports in addiction treatment. Sadly, such is not the case as we are not even told what specific treatment these patients were receiving, so we cannot generalise to other settings. Also, there was no control group, making the conclusions of limited value.

The authors found unsurprisingly that improved retention and other outcomes in those who used extra support in ten main areas (legal services, nutrition, child care, education, domestic, housing, medical care, mental health services, transport, vocational services). Their almost 'motherhood' conclusion states that the findings "support policies that address clients' broader biopsychosocial needs while substance abuse treatment is provided". This is hardly surprising, but sadly it is the sort of argument used by some in the methadone "industry" and government to support limiting methadone treatment to formal clinics in the US. Yet 'medical' methadone using community dispensing is used successfully overseas as well as in numerous American trials.

Supervised methadone in opioid dependent citizens is the most common and best evaluated treatment. Yet inexplicably, I could not find mention of methadone in the entire 10 pages of this article which looked at outcomes at 3 and 12 months. While a range of treatments should be available to opioid dependent patients, methadone maintenance treatment (MMT) is often chosen treatment by heroin dependent subjects. The availability of MMT and its quality are known to be most important factors in (1) attracting patients, (2) retaining patients in treatment and (3) improving important outcome measures, including viral transmission and mortality from all causes. The outcome of excessive prescribing may be overdose death and inadequate doses may lead to early drop-outs, which can also lead to fatalities. Poor psychosocial services could also have untoward consequences in a proportion, although details have never been examined, but usually only their existance and utilization by trial subjects.

It is unfortunate and extraordinary that these researchers could closely examine one aspect of treatment while ignoring other crucial elements, especially those already known to directly affect outcomes. Methadone dose, administration and additional psychosocial supports have long been known to influence outcomes ... in some cases dramatically. I can see little scientific or clinical relevance for this odd item which seems to lack clinical input, except to almost completely ignore therapeutics which necessarily must occur hand in hand with psychosocial services in those who continue to attend for treatment. It is disappointing that there were apparently no physicians involved in this paper.

We know that even with rudimentary ancillary services, prescribed methadone with sufficient dose levels and supervision is highly efficacious, enabling most subjects to regain their independence rapidly (Yancovits 1991, etc). The remainder clearly need more help and these can be recognised in the clinical setting within weeks of starting treatment. While possibly beyond the scope of this study, those who need most help are, paradoxically, those who drop out of treatment early. While these researchers found that most subjects had a need for at least one wrap around service in the course of treatment, this probably applied to those giving the treatment as well (and those reading the article!).

comments by Andrew Byrne ..

BMJ article. More deaths in ‘successful’ detox cases.

Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. Strang J, McCambridge J, Best D, Beswick T, Bearn J, Rees S, Gossop M. BMJ 2003 326:959-960

Dear Colleagues,

Concerned about the excessive overdose mortality in England in heroin users, Strang had the excellent idea of looking prospectively at detox candidates. This showed that out of 137 inpatient detox subjects 5 (3.6%) had died within a year. This is within the reported ranges for opioid dependent populations not in maintenance treatment (2 - 7%pa). Three deaths were overdoses and the other 2 may have been drug related (infection and renal failure in relapsed patients). However, and most importantly, these Maudsley researchers managed to contact and interview most of their survivors (103, 78% at a mean of 9 months). This confirmed strong associations with death vs. survival (1) living alone (80% vs 16%) and the possibly related matters of (2) spending longer in detox (25 vs. 15 days) and (3) completing 28 day detoxification (100% vs 67%). Consistent with other studies, all deaths were male and were more likely in intermittent users cf. regular heavy users. Sadly, of the 71% who were prescribed methadone the mean reported daily dose was approximately 29mg (sd ~23mg). Professor Strang's own recommendations are for a minimum of 60mg to be effective. These patients may have been offered inadequate and therefore ineffective methadone treatment. Such a situation may have seen patients who were not "ready" for detoxification applying for it.

Is it disappointing that despite follow-up questionnaires, we are not told what proportion of detox patients remained opioid-free at 9 months, although we are told that only 37 (27%) achieved complete abstinence and became what these researchers call 'lost tolerance' (LT) category. All 5 deaths came from this small group, thus yielding a mortality amongst 'successful' detox subjects ('completers') of 13.5% at one year (and 3 were dead within four months).
There have now been at least five good studies showing apparently increased mortality in heroin addicts who have detoxed from opioids including prison discharges (references below). Each adds to the now very worrying literature on overdose deaths.

There can be few who could be more deterred by legal sanctions against heroin use than recently released prisoners. Yet it is these very people who are at very high risk of both drug use and complications from that use, including risk of death (up to 14 fold in one study). It is believed that the reduced tolerance of people who have undergone any form of detoxification (including 'rapid detox') may render them at higher risk from overdose on illicit drugs of unknown strength.

We know that overdose cases are more likely to be occasional users, live alone, be male and, paradoxically, to have completed detoxification. These authors find the latter outcome 'counterintuitive' but also concede that reduced tolerance and unknown strength of street drugs could be a cause.

This study should not be taken to mean that detox should not be offered, but it demonstrates that it is not an evidence-based intervention and needs to be patient-instigated when other options have been unsatisfactory or inappropriate. Detoxification should never be compulsory since this is known to result in increased death rates as found in rigorous Swedish research.

Education about not injecting alone, using supervised facilities where available and using smaller quantities have the potential to avoid most overdoses.

comments by Andrew Byrne ..

this item: http://bmj.com/cgi/content/full/326/7396/959

Seaman SR, Brettle RP, Gore SM. Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ 1998; 316:426-428

Miotto K, McCann MJ, Rawson RA, Frosch D, Ling W. Overdose, suicide attempts and death among a cohort of naltrexone-treated opioid addicts. Drug and Alcohol Dependence (1997) 45:131-134

Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-associated relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. (2003) Lancet 361:662-668

Grönbladh L, Öhlund LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand 1990; 82: 223 - 227.
Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study Strang J, McCambridge J, Best D, Beswick T, Bearn J, Rees S, Gossop M. BMJ (2003) 326: 959-960

Darke S, Hall W, Kaye S, Ross J, Duflou J. Hair morphine concentrations of fatal heroin overdose cases and living heroin users. Addiction (2002) 97:977-984