Recovering Smiles Providing Oral health to people in recovery

WHAT IS RECOVERING SMILES?

Helps people in recovery overcome barriers to getting dental care by guiding them through the process and providing a place where they feel comfortable

An education program started in 2013 as a pilot for ATR in Spokane County

Pathway for adults in drug and alcohol recovery to access quality oral health and dental referral services

RS is offering oral health care to a population that is overlooked and desperate for a fresh start

PARTNERS

Eastern WA Dental Hygiene Clinic Access to Recovery DBHR/DSHS Spokane County Community Services Yakima Valley Farm Workers Clinic Riverstone

Family Health Empire Health Foundation Spokane District Dental Society

PRESENTLY RECOVERING SMILES REACHES

Persons in Recovery who at least 60 days Outpatient treatment ATR client present and past

RECOVERING SMILES PROGRAM

Pre-Orientation / Registration and screening for enrollment in WAH or QHP with dental

Orientation—video on expected behavior One-on-One phone conference call Follow-up call after first appointment

Strong No Show and Harassment Policies—ONE

AND YOUR DONE!

PATIENT PERSPECTIVE DENTIST & HYGIENIST PERSPECTIVE Unfamiliar with setting and

changing appointments Lack of trust Fear that their dental needs will

require pulling all their teeth and needing dentures

Does not know how to handle use of drugs before and after procedure

Fear of being honest about their addiction

Past experience with patient in recovery as “no-shows”

Past experience with unruly behavior from patients in recovery

Does not understand their drug needs

Concern that cost per hour in the chair will be too high for overhead

PRELIMINARY OUTCOMES

100% are signed up for WAH or QHP 95% have WAH 169 attended an Orientation 95% attended their first appointment Types of dental issues- periodontal disease,

cavities, abscesses, chipped and missing teeth 5 Average number of visits per client

ORAL HEALTH IMPLICATIONS OF RECOVERING SMILES PATIENTS

DENTAL IMPLICATIONS OF METH

Rampant Caries-smooth surface and interproximal Most likely caused by;

Severe xerostomia Extended periods of poor hygiene High caloric diet with lots of sugar Carbonated beverages Severe bruxism Some speculation that the high acidic properties of drug

has some effect

9

http://www.ada.org/en/member-center/oral-health-topics/meth-mouth

DENTAL IMPLICATIONS OF HEROIN

Caries and Periodontal disease was statistically significantly higher in a heroin addicted group studied in 1971

Most addicts reported a higher craving for sweets and low rate of homecare-many never brushed

Analgesic effect can allow a client to ignore tooth pain Xerostomia Nausea and vomiting due to heroin use can cause

acidic erosion of the anterior teeth

Free Template from www.brainybetty.com

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Gurpreet, K.S., Gupta, N., Prabhat, K. (2013) Drug Addiction and Periodontal Diseases, J Indian Soc Periodontol. 2013 Sep-Oct; 17(5): 587–591.

UNUSUAL SIDE EFFECTS FROM HEROIN

Heroin can be cut with arsenic This will cause purple pigmentation on gums

due to arsenic poisoning Harder to numb the client-some never get fully

numb

Higher risk of bacterial endocarditis for all IV drug users-need to consider antibiotic premedication

Free Template from www.brainybetty.com

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Gurpreet, K.S., Gupta, N., Prabhat, K. (2013) Drug Addiction and Periodontal Diseases, J Indian Soc Periodontol. 2013 Sep-Oct; 17(5): 587–591.

OROFACIAL SIGNS AND SYMPTOMS OF CHRONIC COCAINE ABUSE Snorting loss of nasal hairs nasal crusting sinusitis/halitosis nosebleed nasal septal defect saddlenose deformity palatal perforation erosion of turbinates,

ethmoids, medial sinus walls, cribriform plate, and orbital walls

loss of smell loss of visual

acuity/diploplia CSF leak (cerebrospinal

Fluid)

Gingival application mucosal ulceration necrotizing ulcerative

gingivitis rapid gingival recession dental erosion possible corrosion of gold

restorations

Free Template from www.brainybetty.com

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DENTAL IMPLICATIONS

Many addicts test potency of cocaine by rubbing on their gums creating a burned area

Tissue on lower anteriors may be totally denuded Erosion of dentin and enamel-has been implicated in erosion of gold crowns Chronic users develop bruxing problems-developing severe erosion on

occlusal surfaces Xerostomia Candidacies infections Immediate use after extraction can lead to hemorrhage

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Gurpreet, K.S., Gupta, N., Prabhat, K. (2013) Drug Addiction and Periodontal Diseases, J Indian Soc Periodontol. 2013 Sep-Oct; 17(5): 587–591.

SO WE ASKED WSU SCHOOL OF PHARMACY WHAT THEY SAID ABOUT MARIJUANA….

Marijuana is 70% more toxic than cigarettes It stays in the tissues and kidneys for 13-45 days! It metabolizes lidocaine like crazy, so these folks can’t get numb, or stay

numb The actual psychological effects are about 20 minutes.

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NEW INFORMATION COMING OUT

While rare there is a higher risk of stroke in patients under 33 who use cannabis

These strokes happened while smoking or 30 minutes after-meaning they could be in your chair if they “premedicate” with marijuana

Maybe related to concurrent alcohol use or sexual activity

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Stroke. 2013;44:1-6. Published online December 27, 2012

DENTAL IMPLICATIONS

Higher risk of periodontal disease and caries rate (xerostomia)

Higher risk of oral cancer or pre-malignant lesions Prone to oral lesions due to immunosuppressive

properties Epinephrine may prolong tachycardia Clients on marijuana during appointment may

experience acute anxiety and/or paranoia

16 http://digital.library.adelaide.edu.au/dspace/handle/2440/16775

TREATMENT PLAN MODIFICATIONS

Local anesthetic will not work as well within a few hours of last dose

Xerostomia is a problem so need to address with appropriate products

Large doses=orthostatic hypotension Higher risk of oral cancer so need close

monitoring

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OPIATES AND ORAL IMPLICATIONS

ORAL IMPLICATIONS

Higher prevalence of caries Multifactorial-personal neglect, money goes toward

obtaining drug so little money for prevention or dentistry, higher diets in prepared food, opioids increase craving for sweets

Higher prevalence of periodontal disease Personal neglect, xerostomia Necrotizing ulcerative gingivitis more prevalent due

to neglect, immunosupression and high use of tobacco

Titsas, A. Ferguson, M. (2002) Impact of opiod use on dentistry. Australian Dental Journal ;47:(2):94-98

ORAL MANIFESTATIONS OF METHADONE

Xerostomia (often from antidepressants) Immunosuppresion due to secondary causes (HIV, etc) Increased sugar craving Analgesic effect masking pain

They could have broken teeth or abscesses and not feel pain

Bruxism Has been reported 50% of patients have mental issues leading

to dental anxiety Class V decay-but not as bad as Meth Mouth Delivery is in a sweetened syrup

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Brondani, Park (2013, January) Oral Implications of Methadone, JDH

CLINICAL IMPLICATIONS OF METHADONE

At the beginning of methadone treatment-very short appointments

May have to treat the decay first May need multiple extractions Then move to dental hygiene therapy when the

client feels more comfortable

21 Brondani, Park (2013, January) Oral Implications of Methadone, JDH

TREATMENT PLAN MODIFICATIONS FOR CLIENT WITH OPIATE ADDICTION

Exhibit higher dental fear than general population

It has been demonstrated that clients on methadone have a higher fear of needles than general population

Higher chance of low success with local anesthetic (they just do not numb as easily or stay numb)

Pain management is very critical Titsas, A. Ferguson, M. (2002) Impact of opiod use on dentistry. Australian Dental Journal ;47:(2):94-98

The impact on our students and our clients

RECOVERING SMILES

SERVICES PROVIDED AT EWU

A full mouth series of radiographs Dental Exam Periodontal Chart to assess dental therapy

needed Three levels of cleanings Sealants Filings (silver and tooth colored)

EWU VIDEO FOR RECOVERING SMILES

WHAT DO OUR CLIENTS SAY?

“Sue” When entering treatment not sure of all the

services that were available Referred to the Recovering Smiles Program

from her counselor at YFA Counselor followed up and encouraged her to

sign up

BEFORE SHE CAME TO ORIENTATION

She was very nervous that she would be treated differently-”second class citizen”

Once she got to orientation she appreciated the humor and caring attitude from everyone involved in orientation

She felt the students and faculty were very warm and welcoming

AT EWU

Not treated any different than when she was at private dentist

Students and faculty were very professional Explanations of needed treatment were in

depth and easy to understand Just felt welcomed

WHAT STUDENTS SAY…

Before seeing the client: afraid that since these clients were former drug users they would not take dental health seriously

Orientation is fantastic! Once I saw the client I realized how much they

care about their oral health Appreciate being very open about their past

WHAT THEY WILL TAKE INTO PRACTICE

After seeing these clients it is obvious they fell that these clients by far are respectful and take responsibility

They would tell their dentist(s) they work for about the program and encourage their participation in the program.

TO SUM IT UP…

“More than anything I learned to not judge someone based on their past because they actually could be the client that is willing to make the most changes in their oral health. I quickly realized how much respect I have for those who are able to overcome their addictions and get the help they need. ”

Roadblocks

AVAILABILITY OF SERVICES

IMPACT OF UNMET DENTAL NEEDS IN SPOKANE COUNTY

In 2013 there were 901 visits to ER that were dentally related

23% of those visits were from duplicates (2 or more visits)

Hospital Charges: $588,653.33 DSHS reimbursement: $88,298-15% of

customary and usual charge Based on the average charge of $653.33 each

APPLE HEALTH

Yeah they pay! But reimbursement is not enough to cover

expenses Not many dentists are willing to take on burden

of losing money for clients that historically have a high no-show rate (DSHS)

HOW ARE WE STARTING TO ADDRESS THE PROBLEM

Orientation explains benefits, puts a face to the people they will be seeing (faculty and students)

One and your done-reduces no shows! Forging relationships with Yakima Valley

Farmworkers Clinic in Spokane to see the client for work that is beyond EWU dental hygiene clinic

Also have 2 denture clinics on board Recruiting private practice dentists to take a

couple of these clients

CONTACT INFORMATION Georgia Butler Community-Minded Enterprises 509-209-2864 georgiab@community-minded.org Lisa Bilich EWU Dental Hygiene 509-828-1295 Lbilich @ewu.edu