Dental ramifications of cocaine useFeatured Products Promotional Features
Posted by: The Probe 14th January 2020
Despite strong legal provisions and decades of anti-drug programmes, drug abuse is still prevalent in the UK. According to government statistics around a fifth of young adults (16-24), and nearly a tenth of adults overall, had taken illicit drugs within the preceding year, with an upward trend in the use of Class A drugs.[i]This trend is primarily being driven by the increasing availability and affordability of powder cocaine.[ii]Among other consequences, cocaine usage can damage the tissues of the orofacial region. With the number of adults partaking, some of your patients are likely to exhibit symptoms driven or exacerbated by drugs.
Cocaine is primarily taken for its mood and confidence enhancing effects, though it can also trigger negative emotional states such as paranoia and irritability. Beyond its numerous psychoactive effects, while cocaine is active in a person’s system a plethora of side-effects can occur. These include hyperthermia, hypertension, tachycardia and increased/decreased respiration. Both the dosage and the individual’s constitution can alter the nature and degree of these immediate effects.[iii]
Cocaine increases heart rate and increases the oxygen demands of the myocardium. Simultaneously, it provokes vasoconstriction of the coronary arteries decreasing the oxygen supplied to these tissues. These combined effects can lead to angina, myocardial infarction or cardiac dysrhythmias. Further vasoconstriction throughout the body increases arterial blood pressure up 15-20% above the individual’s usual levels. Acute hypertension is dangerous and can cause aortic dissection, or even a brain aneurysm.[iii] It is recommended that emergency dental procedures be avoided when a patient’s blood pressure exceeds 180/110 mmHg. This applies generally, regardless of the whether patient is a drug user.[iv]
Cocaine increases the effects of epinephrine, which is frequently used as a vasoconstrictor in local anaesthetics, which can potentially increase the risk of cardiac event or stroke. Cocaine can also interact with lidocaine, increasing the risk of convulsions.iii
Long-term cocaine use can have severe consequences in the orofacial region. More than half of users develop olfactory changes and chronic sinusitis, while one in twenty manifest nasal septum perforation. The vasoconstrictive properties of cocaine induce local ischemia, which can cause tissue necrosis. It also dries the nasal cavity, causing crusts to form and increasing susceptibility to infection. Some users pick at these crusts (sometimes with an implement such as a pen), further increasing the chance of perforation.iii
The same necrotic effect can result in palate perforation (mostly in the hard palate). This can affect speech, and result in nasal regurgitation during eating and drinking. Some patients attempt makeshift fixes by blocking such perforations with materials such as chewing gum, tissue paper and bread. Women appear to be more susceptible to palatal damage, making up around 80% of cases.iii
Cocaine is sometimes rubbed into the gums. Using cocaine orally in this way can result in localised gingival lesions and retraction. This in turn can lead to substantial alveolar bone loss. Cocaine-induced gingival abnormalities are potentially reversible, provided the patient abstains.iii
In addition to the above, cocaine raises the risk of lesions in the oral mucosa and increases the risk of periodontal problems. It may also raise the risk of xerostomia, temporomandibular disorders, cervical abrasion and increase the rate of tooth decay and susceptibility to infections.[v],[vi]
Cutting, mixing and drug interactions
While purity has generally increased in recent years, of all illegal drugs cocaine is the most frequently cut with other substances. At street-level distribution, seized samples have been found to be mixed with an average of three other substances (sometimes many more). These can dilute or intensify the effects of the drug, and can be damaging in and of themselves. Common cutting agents include: sugars, talcum powder, plaster, starch, amphetamines, anaesthetics. The veterinary anthelmintic levamisole is very widely used due to its availability, as is the analgesic phenacetin.ii Given the illicit nature of the substance, its manufacture and distribution, users have no accurate way of ascertaining what exactly they are taking.
Discussing with patients
Regular cocaine usage is a destructive, but highly addictive habit. Where you recognise signs of probable drug abuse, approaching the patient in a neutral informative way is helpful. Given the damage cocaine can do to the orofacial region, you are not unlikely to be the first healthcare provider to detect the problem. Some of the damage from cocaine can heal, while other symptoms require intervention, provided the patient is able to quit.
Alongside advice concerning drug usage, a great deal of good can come from helping the patient better understand and adhere to an oral hygiene routine. A Water Flosser can be an excellent recommendation, as it is an easy way to effectively floss. The Waterpik®Water Flosser helps reduce gingivitis and bleeding.[vii],[viii]Immediately, fully treating patients suffering from the consequences of addiction is not always possible without cessation of the habit. During this time, ensuring the patient is doing their best to manage their oral health can help minimise some of the likely complications.
For more information on Waterpik® products please visit www.waterpik.co.uk. Waterpik® products are available from Amazon, Asda, Boots and Superdrug online and in stores across the UK and Ireland.
[i]Home Office Statistics. Drug misuse: findings from the 2017/18 crime survey for England and Wales. Home Office.2018. https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2017-to-2018-csewJuly 25, 2019.
[ii]European Monitoring Centre for Drugs and Drug Addiction. Recent changes in Europe’s cocaine market. Publications Office of the European Union.2018.http://www.emcdda.europa.eu/system/files/publications/10225/2018-cocaine-trendspotter-rapid-communication.pdf
July 25, 2019.
[iii]Blanksma C., Brand H. Cocaine abuse: orofacial manifestations and implications for dental treatment. International Dental Journal. 2006; 55(6): 365-369. http://dx.doi.org/10.1111/j.1875-595X.2005.tb00047.xJuly 25, 2019.
[iv]Popescu S., Scrieciu M., MercuţV., Ţuculina M., Dascălu I. Hypertensive patients and their management in dentistry.Hypertension. 2013; 2013: 410740. http://dx.doi.org/10.5402/2013/410740July 25, 2019.
[v]Tsoukalas N., Johnson C., Engelmeier R., Delattre V. The dental management of a patient with a cocaine-induced maxillofacial defect: a case report. Special Care in Dentistry. 2000; 20(4): 139-142. https://www.academia.edu/11208958/The_dental_management_of_a_patient_with_a_cocaine-induced_maxillofacial_defect_a_case_reportJuly 25, 2019.
[vi]Maloney W. The significance of illicit drug use to dental practice. Webmedcentral. 2010; 1(7): WMC00455. https://www.webmedcentral.com/wmcpdf/Article_WMC00455.pdf
July 25, 2019.
[vii]Barnes, CM, Russell CM, Reinhardt RA et al. Comparison of irrigation to floss as an adjunct to tooth brushing: effect on bleeding, gingivitis and supragingival plaque. J Clin Dent. 2005; 16(3): 71-77. https://www.ncbi.nlm.nih.gov/pubmed/16305005July 25, 2019.
[viii]Jolkovsky DL, et al. Clinical and microbiological effects of subgingival and gingival marginal irrigation with chlorhexidine gluconate. J Periodontol. 1990; 61: 663-669. https://www.ncbi.nlm.nih.gov/pubmed/2254831July 25, 2019.