Archive for October, 2012

Oral Health: A Window To Drug Addiction

Monday, October 8th, 2012

By: Victor J. DeNoble, Ph.D. & Kimi F. DeNoble, MS

Research has shown that oral health problems are very common among people who are addicted to drugs.  Many abused drugs produce chronic tooth decay, cracked teeth, gingivitis and other forms of gum disease.  For example, alcohol is high in sugar which contributes to an increase in tooth decay and frequent chronic consumption can de-mineralize tooth enamel.  Stimulants like ecstasy, amphetamines or cocaine cause severe clenching and grinding of teeth, as well as dry mouth when the individual is under the influence of the drug.  Users of stimulants are also known to have a high intake of sugar.  This combination of side effects can cause serious tooth decay.  Methamphetamine prevents saliva from being produced that results in a condition called “meth mouth” which is characterized by discoloration, rotting and broken teeth, as well as  extreme tooth decay.  The chemical composition of methamphetamine includes a wide range of highly toxic chemicals such as lithium, and muriatic and sulfuric acids all of which are highly corrosive.  Tobacco can cause a wide range of oral problems such as delayed wound healing, sinusitis, soft tissue damage and oral cancer.

Because the relationship between substance abuse and oral pathology is well documented, the dental visit can provide the ideal setting for drug abuse identification and intervention.  In addition, having an understanding drug addiction will assist dental professionals in making decisions when medications with potential for abuse are being considered as part of the overall treatment paradigm for these patients.

Years ago, drug addiction was viewed as a character flaw, an inability to control one’s own behavior.  Today, we know that drug addiction is a disease.  Further, it is a self-inflicted disease; no one addicts us, we addict ourselves.  The motive for drug addiction varies from person to person but the decision to use and eventually abuse the drug is still an individual choice.  Drug addiction is not an event that happens all at once.  It’s a biochemical process that takes time and will eventually result in long-term changes in brain function.  These changes are the underlying mechanism for compulsive drug abuse.  The time it takes to complete this biochemical change varies for each drug.  For some drugs like methamphetamine or crack cocaine, the brain changes can occur in one to three weeks. However, with other drugs such as alcohol or tobacco, the process can take several months.  No matter how long or short the process is the first time, re-addiction for all drugs is fast – – sometimes it can occur within a day.  Therefore, once you are addicted to a drug, you are at risk for re-addiction for the rest of your life.  This makes the choice of pain management medication in dental and medical procedures more difficult.

Everyone is born with specific areas of the brain that recognize and respond to addictive drugs; therefore no one is immune from addiction.  In fact, we are all at risk for addiction.  Once an addictive drug enters our blood, it will be transported to the brain and the process of altering brain function begins.  But why do people use addictive drugs?  Simple.  Addictive drugs make us feel good, at least for a brief period of time.  The major neurotransmitter mediating the addictive process is dopamine.  Dopamine has a wide range of functions in the brain, however, the feeling of happiness is mediated in the mesolimbic system. The mesolimbic system is commonly called the “pleasure center”.  When dopamine levels are normal, we feel comfortable.  If they fall, we can be depressed and, if they rise sharply, we can experience euphoria.  All drugs that are addicting change the way dopamine functions in the mesolimbic dopamine system.  The mechanism for dopamine alteration for each addictive drug is different.  These different mechanisms explain why we can be addicted to several drugs at the same time.  Unlike the normal release of dopamine, when drugs are used to activate this system the resulting dopamine response goes far beyond what the system is supposed to produce and the process of addiction begins.

Addictive drugs make us feel good but the feel good feature of these drugs does not lead to health problems.  Aside from the oral manifestations, these drugs have a wide range of pharmacological side effects that have  other health consequences.  For example, cocaine makes us feel good for about 40-60 minutes, however, the side effects of cocaine put the user at risk for potential life threatening conditions for days.  Atrial fibrillation induced by cocaine has been shown to last for up to 3 days whereas cocaine is metabolized and excreted within 24 hours.  Cocaine renders the addict at risk for heart attacks, strokes, kidney failure and pulmonary embolisms.  Each addictive drug has its own constellation of unique side effects that can be further reviewed at the National Institute of Drug Abuse website.

Research has shown that drug addiction results in dental complications many of which will appear before other less visible complications, e.g., organ failure.  Since many Americans visit their dentists more often than they visit their physicians, dental professionals have an increased likelihood of detecting drug abuse and therefore an increased potential for intervention.

 

Dr. DeNoble has a Doctorate in Experimental Psychology from Adelphi University, NY and two postdoctoral fellowships from NIAAA and NIDA.  He was recruited by Philip Morris to study the behavioral and physiological effects of nicotine on the brain.  He subsequently conducted drug discovery research in CNS diseases for the pharmaceutical industry.  In 1994, after a congressional release from a confidentially agreement with Philip Morris, he testified before Congress and became a key witness in the federal government’s case against the tobacco industry. Currently, he is the Vice President of Hissho, Inc., a scientific and medical communications company.

Cavity Management by Risk Assessment Improves Access to Care

Monday, October 1st, 2012

By Dr. V. Kim Kutsch, DMD

Recently PBS broadcast a Frontline special report entitled “Dollars and Dentists”. The report presented a “broken dental system” in the US, amidst a rising epidemic with decay. PBS actually did a very good job describing the current issues facing dentistry today: rising healthcare costs, increasing decay rates in children and adults, limited access to care, an entitlement system that doesn’t adequately reimburse private practitioners, and corporate America seeing a profit opportunity in treating (mistreating) these children, and the concept of mid-level providers to help solve the access issue. However, the report failed to examine the real issues at play, and missed a huge opportunity to report the truth.

Here are the facts: the decay rate in our small children is rising at epidemic proportions, there is limited access to care, but the focus of the system is still in the wrong place. The Medicaid system will reimburse for crisis care for a child in a hospital setting to the tune of $12-18,000, and again when the same child needs the same procedure 20-24 months later, but won’t adequately reimburse a private practicing dentist to provide the necessary preventive management to avoid the crisis in the first place. What part of this expensive, out-dated system should we consider successful?

Corporate America got involved and suddenly there is an increase in the number of stainless steel crowns being placed on these children and less preventive services. Is anybody really surprised by that? The system rewards placements crowns but doesn’t adequately compensate a private practitioner to provide real preventive care and counseling. What might happen if the system paid $300 for fluoride varnish, professional therapy products, and nutrition counseling and $30 for a stainless steel crown?  There would be a lot fewer stainless steel crowns and there might also be fewer $18,000 crisis scenarios and better treatment outcomes.

Organized dentistry provides a lot of free care to help with the epidemic, take the success of the MOM program for example, or Donated Dental Services. Or consider the fact that individual dentists routinely provide pro-bono care to people in need. This was never mentioned in the report, but we all donate care as best we can. Unfortunately it still isn’t enough for the crisis we’re in.

Dr. Bob Barkley summed it up pretty accurately over 40 years ago. The problem we have is the house is on fire, and we’re trying to solve the problem with carpenters. We need to send in the firemen. The bottom line is dental caries is a multifactorial, complex, pH-specific biofilm disease. Too late we’ve learned that the drill has little to do with actually treating the disease. Increasing the number of Pediatric Dentists, operating suites, corporate dental practices, or mid-level practitioners isn’t going to solve this epidemic. We can’t drill and fill our way out of this crisis, regardless of who is running the drill. We don’t need more carpenters. We need to put the fire out.

To solve the healthcare crisis we face in dentistry today, we need to move from a treatment model to a healing model. CAMBRA, or caries management by risk assessment identifies and addresses the cause of the disease for each patient. By understanding the cause of dental caries we can focus on targeted strategies and effectively manage it. Armed with this knowledge we can coach patients back to long-term sustainable health. Through real preventive management of this disease we can provide the treatment outcomes we are looking for. The system we’ve got is truly broken and not functioning. The decay epidemic is direct evidence of that. But the solution won’t be found incarpenters, we need to change the “system” so that it fairly rewards firemen. That would reduce the decay epidemic, reduce the cost burden, improve access to care, and provide a genuine long-term solution. We need to fix the system. That’s the real story, and Frontline missed it completely!

 

 

Dr. Kutsch received his undergraduate degree from Westminster College in Utah and then completed his DMD at University of Oregon School of Dentistry in 1979. He is an inventor, product consultant, internationally recognized speaker, in past president of the Academy of Laser Dentistry, and WCMIID.  He has also served on the board of directors for the WCLI and AACD.  As an author, Dr. Kutsch has published dozens of articles and abstracts on minimally invasive dentistry, caries risk assessment, digital radiography and other techonologies in both dental and medical journals and contributed to several textbooks. He also acts as a reviewer for several journals.  Dr. Kutsch also serves as CEO for Oral biotech, as a clinician.  He is a graduate and mentor in the prestigious Kois Center and maintains a private practice in Albany, Oregon.