Scope of Prevention:Preventing Relapse by Providing Comprehensive Oral Health Care w/ SUD Treatment


>>Good afternoon everyone. We’re going to get started with our webinar. The Mountain Plains Prevention Technology
Transfer Center at the University of Utah is excited to welcome you
to our five part webinar series; Scope of Prevention Along the Continuum of Care. A recording of this webinar will be posted on
our website at pttcnetwork.org/mountainplains. Slides will be available in PDF format
and posted on our website as well. For those of you interested in a
certificate following today’s webinar, please email [email protected] We are an approved NADAC provider. For all other licensure and credentials,
please apply directly to your board. All participants have been muted. We encourage you to use the chat
feature for questions and messages. Following the webinar, you will see
a link in the chat feature along with a QR code to complete a survey. The survey is required for all training
events funded by substance abuse and mental health services administration. They want to know how well
we provide our services and we want your feedback to
help us improve our training. The information you provide is confidential. We ask that you please take a few minutes
to complete the GPRA evaluation form. The purpose of this webinar series is to
discuss strategies and interventions used to prevent substance use,
decrease risk of substance use or if substance use has already
occurred, as well as to discuss strategies for preventing relapse after treatment
or during maintenance and recovery. Components of the institute of medicine
or IOM, Behavioral Health Continuum of Care model will be highlighted and
discussed throughout the webinar series. In this webinar series, we want to highlight that prevention can occur anywhere
along the continuum of care. Including during treatment
and maintenance and recovery. Before we dive into IOM’s Continuum of Care
model, we want to acknowledge that some of you may be familiar with slightly
different prevention models depending on the setting you work in. For those of you who participated
in our last webinar series, we discussed some of the different
prevention frameworks and models. For example, many of you are familiar
with Census Strategic Prevention Framework which is more of a comprehensive
framework or planning process to prevent substance use and misuse. However, some of you may also be familiar with
the prevention triangle which is often used in schools and other educational settings. We want to point out that all of these models
are complementary rather than exclusive. Many of you may be familiar with the IOM Mental
Health Intervention Spectrum model published in 1994 that offers the framework for
addressing behavioral health including substance use disorders. This model begins with promotion and
prevention treatment and maintenance recovery across the continuum, while recognizing that promotion also occurs
across the entire continuum. Today’s webinar will focus on
prevention within treatment and recovery. Other webinars in this series will focus
on other components of the IOM continuum. It is my pleasure to introduce
our presenter today. Dr. Glenn Hanson received his DDS from
UCLA in 1973 and his PhD in pharmacology from the University of Utah in 1978 and
completed a fellowship in neural pharmacology in 1980 at the National Institutes
of Health or NIH. He practiced dentistry full and
part-time over a ten-year period. Dr. Hanson is a tenured full Professor of
pharmacology and Vice Dean in the School of Dentistry at the University of Utah. He was acting director of the national Institute
on drug abuse at the NIH and is recognized as a leading expert on the
neurobiology of the psychostimulants. Dr. Hanson has given hundreds of
presentations around the world on his research and program development related to drug
abuse in the public health implications. He also has specified multiple times before
the United States Congress and the state of Utah legislature on issues of drug abuse
policy and Medicaid dental strategies. He is a member of the state of Utah
legislative advisory committee on drug abuse. Sorry. Drugs of abuse, excuse me. He is an author of over 240
peer-reviewed scientific papers, 13 editions of a textbook entitled Drugs and
Society and has been awarded over 35 million in NIH grants to conduct research
related to drug abuse and its treatment. It is my pleasure to turn
the time over to Dr. Hanson.>>Thank you Taylor. I appreciate that introduction
and just to lay the groundwork, this is going to be a presentation that
for most of you, will be a little different in that we are introducing a
component that isn’t often discussed. I mean, it’s identified. It’s recognized. People know that it’s there but its
involvement in the substance use disorder models as we relate to things such as prevention
and management, isn’t fully appreciated and that is the issue of oral healthcare. Now because of my background as a
dentist and then later on in my career, I got involved in issues related to
substance use disorder treatment. And then the time I spent at the National
Institute on Drug Abuse and helping to direct some of the programs there, I started
to get this vision of the comprehensive model for addressing problems associated
with substance use disorder. And when I was at NIDA, I thought a lot about
this correlation between substance use disorder and oral health and that many
of those individuals who suffer from SUD problems have major oral health issues. And I kept thinking, you know
there’s something going on here. There’s some interaction that’s taking place. It would be nice to sort that out and maybe
there could be some strategies that would evolve that could be of value in helping to work
with these patients both in treating them, preventing relapse or even in prevention. But it wasn’t really until I came back to
the University of Utah, after leaving NIDA and we started a new dental school, that I
had the opportunity to start to integrate some of my dental background into my substance
use disorder research and interest. And it’s that topic that I really want to
focus on today and maybe give you a perspective that many of you’ve not had and also talk
about where we might go with this correlation between oral health care and treatment
or management of substance use disorder. Let me start, first of all Excuse me. Just having a little technical problem there. Let me start off first of
all with where we kind of are in substance use disorder programs
relative to oral health practice. As I said, I think everybody that works in
this area knows that a lot of our clients, our SUD clients have problems with oral health. Actually, the treatment programs have little
involvement in trying to figure out how to address the oral health side of these
folks and one of the major reasons is that we don’t have the resources. So monies that come from either
governmental programs or insurance programs, typically don’t have elements that allow
us to do much with the dental side. We have things that or monies that we can
use for medical and mental health care but the only thing that we
can use or spend our money’s on for dental is just the
emergency temporary dental care. Somebody has acute issues such as pain, we can
spend some of our budgets and help to relieve that pain or if there’s infections, we
can go and take care of the infections. And the strategy is we’ll give medication. We’ll prescribe something for
the pain or for the infection or maybe there would be surgery
involved such as extractions. But that’s about it. Just the emergency issues
straightforward and then we’re back to the regular program and
there’s not much else. There’s no comprehensive
strategy that’s out there. And so the problem on the dental side relative to substance use disorder
hasn’t been well studied. there anecdotal stories out there and
everybody recognizes that it’s an issue but, the anecdotes, the reports are somewhat variable because they haven’t been
evaluated in a scientific approach. And so let me just start off before
I talk about research we’ve done, just let you know what we have
found in our recent studies and these were done using traditional
evidence-based examinations. And what we saw in our group of
patients, one we saw that about 40 percent of our substance use disorder patients
or clients at major oral health needs. So that’s not 100 percent. But it’s approaching almost half
of these patients had major needs which I will define for you here in a second. In our group, most of those were heroin or open
your use disorder patients interestingly enough. But I was a little surprised with
that because you hear a lot of stories about methamphetamine are
mouth-to-mouth and I kind of thought methamphetamine use
would be the top but it wasn’t. It was opioid use. However, meth was close behind
with about 30 percent of those patients having
major oral health issues. So why, why is there such a high
incidence of dental problems in this category or population of patients? Well one of the reasons has to do with
the pharmacology you’re dealing with. Many of these drugs directly because their
pharmalogical properties alter the environment of the mouth and they cause xerostomia or dry
mouth which those of you that are familiar with dentistry and oral health issues,
know that that is not a good thing. When you stop salivation, you
interfere with defense mechanisms. You create an environment where
injection is more likely to occur. And environment where there
could be severe damage done to periodontal as well as to tooth structure. Another potential problem has to do with diet. These folks frequently consume diets
have very high sugar content both in terms of the foods and the drink. They have poor nutrition. All of this may show up with a mouth
that is severely compromised both to the hard tissues as well
as to the soft tissues. And then of course hygiene isn’t
a top priority for these patients. They don’t think about that. Not at least until they have pain or they have
infection and they have to think about going to an emergency room to address the
emergency the immediate complaint. But they’re certainly not thinking long-term
about how do I clean up my oral health problems and how do I identify good oral health. So, what does major oral
health disease typically look like when I say individuals 40
percent or 30 percent whatever that number is, have major oral health disease? What did we find at least in our group
when we defined or looked at this issue? On average we found that these people
required four extractions, meaning the teeth or the supporting structures became so diseased that we couldn’t save them using
standard comprehensive dental management. So the teeth had to be removed. Another thing that we found is in the
periodontal tissues, the soft tissues and the hard tissues had major problems
which required major procedures. And this slide sort of shows you
what those procedures are likely to achieve when they’re done properly. You remove calculus and accumulation
of residual foods. You get rid of the garbage
debris that’s accumulated between the teeth and you try to clean that up. So on average, these patients would
undergo two major periodontal procedures. And then restorations, restorations meaning
fillings, whether they’re amalgam metal fillings or they’re composite feelings, on average
these patients there be about six of those. And then some of these patients would receive
or could receive crowns, porcelain crowns or metal crowns on average one to two patients. So the tooth is restorable
but it needs something more than just a filling in order
to do that restoration. And then some of the teeth are
also restorable but they do need to have a root canal procedure done and
on average there would be one to two of these root canals per patient
and then the final issue is most of these patients have lost teeth and
so half of them will require some kind of a removable denture whether
it’s a full denture on the top or the lower or it’s a partial denture. So half of them would have one
of these removable prostheses. So you look at all of these things and
there’s a lot of stuff that’s going on here. If I were going to do comprehensive
dentistry on this patient rather than just emergency dentistry going in and
pulling teeth, then there’s going to be a lot of dental investment, investment
in time to take care. So what is the impact of the major oral disease? Well one is persistent pain and discomfort. If they don’t get emergency
treatment they’re going to hurt and they’re going to hurt on a regular basis. This is a slide from a patient
who has major oral health problems as well as substance use disorder. It doesn’t take a lot of imagination to
see that this person is very uncomfortable. There are some teeth that have been diseased
all the way through to the crown of the tooth down into the gums and this is not
going to be a comfortable thing. Well, under this kind of condition, there’s going to be infection
and the infection can spread. It can go from the mouth into the periodontal
surrounding tissues and make its way into the systemic circulation and could go
to other tissue areas which are problematic, especially if you’re a patient that has diabetes
or has cardiovascular disease or other organs that are pathologically involved. And then also, the function. It’s going to be hard to chew or hard to
eat with a mouth that has major oral disease such as what you see in the slide. If you can’t eat properly,
you’re going to be malnourished and if you’re malnourished now you’re
going to involve the entire body. If you don’t eat well then nothing works. None of the other organs are functioning
properly and this can be an introduction for other diseases, medical
diseases into these patients. Then other functionality has to do
with interacting with other people, communicating, social difficulties. I’m sure those of you that work and
the SUD arena have seen individuals who cover their mouth. They won’t look at you. They’ll looked down when they talk because
the communication has been compromised. They don’t talk normally. They talk with lisps or other sounds
that are associated with their speech and they don’t feel comfortable
in a social environment. They are self-conscious. They know that people are looking at
their mouths without looking at them and then this kind of leads to this next point. And that is cosmetics. Many of our SUD clients are young. They’re young adults and there’s a
cosmetic stigma that happens here. You don’t have confidence. You don’t have confidence. It can be hard to get a job and so unemployment
is often seen with these individuals and it makes other family members or loved ones
feel very, very uncomfortable as well as full of sympathy for them realizing that they’ve
sort of painted themselves into a corner by allowing their mouths and the oral
environment to get very compromised. So when you add all these things together, you end up with what we refer
to as poor quality of life. Quality-of-life is sort of and all-encompassing
concept that talks about all of these issues. Talks about comfort [inaudible]
talks about sociability. Talks about self-image and ability to get
a job and interact and have confidence. Well, when you’ve got poor oral health,
you have very poor quality of life. There’s a large literature out there that
looks at quality of life as a consequence or as related to medical conditions and there
is a literature that talks about quality of life as it relates to substance use disorder. And there’s an evolving literature
that talks about quality of life, poor quality of life as it
relates to oral health. So all of these things come together. This is a comprehensive model that has an impact
on the expression of substance use disorder and how we can go about trying to treat it. So, with this background,
let’s ask the question, what has science told us
relative to managing oral health? Taking care of the pathology and the poor
oral health, what impact does that have on substance use disorder treatment? We do expect there to be
some kind of a connection. So when you look at the literature,
what do we find? Not much. There just isn’t much out
there that has looked at this connection. There is literature out there that has examined
good primary medical care as it relates to substance use disorder treatment outcomes. But not literature that talks about
good oral health care and how it relates to substance use disease or
disorder treatment outcomes. And so that was a question that I had and
that we had here at the University of Utah. Why don’t we build on what we know about
primary medical care and its involvement in SUD treatment and let’s
take it to the oral health. The oral core or care. How would that be implicated
in managing SUD treatment. Never been tested and we wanted to
do the test and see if we could come up with some interaction between the two
that might educate us or advise us relative to techniques and strategies for prevention
as well as for treatment of SUD problems. So, these are the results of the first
study to specifically look at this issue. At least that we’re aware of and it
was recently published in the Journal of the American Dental Association
last month in July. So this is hot off the press
kind of information. And the study’s title is Comprehensive Oral
Care Improves Treatment Outcomes in Both Male and Female Patients with High-Severity
Chronic Substance Use Disorders. So the title gives you a preview
of what the findings were. And looks like there is a correlation that
comprehensive Oral care may have an impact on how SUD patients respond to treatment. So, just to understand where
this study came from, it originally or it originated from a HRSA. HRSA is the acronym for health
resources and services administration. This was a workforce training
grant that we called FLOSS. And FLOSS is an acronym for
something that you’ll never remember and I almost never remember either. It’s a lot easier to remember
FLOSS then Facilitating a Lifetime of Oral Health Sustainability for Substance
Use Disorder Patients and Families. FLOSS. This FLOSS was a workforce
training program. So, what it was intended to look like originally
was to train managers, individuals who worked with SUD patients, case managers educate
them relative to all oral health elements. In other words, look in the mouths of your
clients and see what their dental needs are. And then also to train individuals who
provide dental care to ask questions about substance use disorder and be educated
relative to the treatment of the prevention or strategies in managing these patients. Or of those individuals who have high
risk for SUD problems, excuse me. And we used as mainstay for training of the
dental care providers SBIRT training and as most of you know, SBIRT is a screening
of evaluating the risk of patients for having problems with drug abuse. And it was very timely that we did this
FLOSS program because we have recently worked with some state legislators to pass a law
from the house that would help train dentists or dental personnel in providing
SBIRT for managing their patients. So the state had already into this concept that
they wanted to see dental providers working with patients that had SUD risks and this law
that provided a way in which this could happen and encouragement to oral care providers
to get into that workspace and talk about and understand SUD clients and how they’re
treated or what their risk look like. So, this program presented an opportunity to
establish a partnership between the school of dentistry and two SUD treatment
programs, well-known programs here in the state of Utah and in Western states. First Step House and Odyssey
House were our partners and we found some very interesting
things that I want to share with you and just talk a little bit about as we go through to help you appreciate
what that relationship was. So what were the principal findings? You can read these in that literature that
general American Dental Association paper. So there were two groups that
were identified in this study. Let me just put this in perspective. The FLOSS grant was to train
workforces so that they would think about if they were SUD caseworkers
that think about oral care. If they were dental workers, they would think
about substance use disorder and they would talk to each other and provide comprehensive support. Originally was not intended to look
at the outcomes which we were able to identify as we went into the program. So, why did we look at these outcomes of
that wasn’t the specific game of the grant? Well the reason we started looking at
SUD treatment outcomes as it related to providing dental care, was about halfway
through the grant as we were meeting with the SUD treatment providing agencies
with Odyssey house and First Step, the people from the houses Odyssey and First
Step, started to notice that their SUD patients that were getting dental care
as part of our FLOSS program, the outcomes had significantly
improved, particularly the outcomes that related to length of stay in treatment. And they started reporting this in our meetings. They said you know we are
observing that those dental, those SUD clients who are getting dental
care are staying in our programs much longer than those clients who do
not receive dental care. And that didn’t surprise me and I don’t think
it surprised other folks from the dental side. But those from the substance use
disorder side were a little surprised that the effect so dramatic. Sort that point we decided to, yeah we
would continue doing the training piece for which the grant was originally identified
but we would also start to pay attention to the assessments that were being done by
the treatment houses, Odyssey and First Step and we identified two groups at this stage. We identified that a group that was receiving
dental care, comprehensive dental care. So all these groups are SUD
clients who are being treated. So but half of them or a portion
of them were getting dental care. The other portion were not receiving dental
care, at least the Comprehensive Care. What they’re receiving is just the emergency;
you know the traditional emergency stuff. If you’re hurt, we’ll take
you to the emergency room or if you’ve got an infection
we’ll gave it extracted. And so the two populations were
divided into the dental care. They’re getting comprehensive dental
care, the DC’s or the non-dental care, those who are just traditional SUD patients but
they’re not getting comprehensive dental care. And we looked at both Odyssey House
findings and we looked at First Step Findings and these are the things that we observed. So, in Odyssey House fortuitously,
and it wasn’t intended and we didn’t provide any specific directions to
Odyssey House as to how to set these groups up. They just kind of did it on their own. And they did it in a randomly
selected manner which is good science. But that wasn’t the original
objective of this grant. It was to train or to teach,
educate, workgroups, how to deal with these other populations. But they looked at almost 300 of their patients. All of which had major dental problems
and they divided them into two categories. Because we only had enough money with our grant
to provide dental care for about 150 patients. So they had the dental care patients,
165 but then they also had a match group that they were watching that didn’t get
dental care and there was 158 of those. So, in retrospect, we were very
fortunate that Odyssey House did this because it gave us a good means of comparison between treatment groups
and non-treatment groups. Findings were fairly spectacular as I implied. They told us that those patients in Odyssey
House and in First Step as you’ll see here in a second, staying much longer if they
were receiving comprehensive dental care. And so, the average for Odyssey
House was almost a year . They were getting comprehensive dental care
compared to their traditionally treated patients which were staying for about four months. So most of you that work in this field know
that the longer you can keep these SUD patients in treatment, the greater the likelihood that
there will not be a relapse or recidivism and the better they’re going to
do and the greater the likelihood that they are actually going to
finish treatment and we observed that. We saw that those who received treatment
of dental care, 63 percent were likely to finish the complete SUD treatment that
those that didn’t receive dental care. This is kind of exciting. It looks really good and in Odyssey House,
they have both male and female clients. So we were able to do some
sophisticated multivariate analysis to see whether the gender made a
difference relative to their length of stay and it didn’t seem to matter. It wasn’t a gender issue. It was did you get comprehensive
dental care issue that determined how long they
stayed in both males and females. So that was exciting. It said comprehensive dental care
does seem to be doing something here for outcomes; SUD treatment outcomes. Then we looked at our First Step House
findings and we saw a very similar thing. Although in full disclosure, FirstStep had
set their groups up in a different way. They didn’t set them up with
a random selection; a model. They set them up with a self-selection model. So patients who came in out of about
1100 patients, those who said you know, I would really like to have
some comprehensive dental care. They informed the patients that they were
part of this FLOSS grant and that some of them could get comprehensive dental
care as part of the FLOSS grant. And they asked them, who would be interested
in having comprehensive dental care and about 150 – 158 of them said hey me. Raised their hand. I would be interested. They self-selected. Another 800 and some weren’t
particularly interested. So, the numbers worked out. We had money as I said to provide careful for
about 150 patients; some of these SUD clients. So it look very much like Odyssey House in terms
of the dental care and we used that other group that weren’t interested in getting
the comprehensive dental care as our non-dental care group and we
made a comparison between those two. So different, a way of identifying the dental
care but still we thought it would be intriguing to see if we saw the same outcome
as we saw with Odyssey house that used random selection and we did. As you can see here the data
outcomes, the dental care, those who received comprehensive
dental care stayed about 240 days whereas the
non-dental care stayed about 152 days. Now as you can see in the patient
demographics, these were all males. There were no females here. So the populations are little different
where they came from was a little different. A lot of those in the First Step House groups
were referred there by drug courts and they in both places, the majority are the highest
concentration of patients were heroin addicts. So it didn’t seem to matter whether they were
male-female or which house they came from. At least in this area heroin had a really
high percentage of these SUD patients and had a high percentage of those
that ended up getting dental care because they had major dental problems. But we also looked at some other
outcomes in the First Step House that we didn’t have an opportunity
to look at in Odyssey house. So we got a bigger picture of
what treatment outcomes look like when you provide good dental care. We found in the First Step House that employment
dramatically improved in the SUD population if they received comprehensive dental care. So the improvement in employment and those that
receive the dental care was 460 percent greater than if they didn’t get treatment. Those who received SUD treatment
but not dental care, improved by 130 percent in
terms of their employment. So there was improvement
there which you would expect. They’re getting SUD treatment but if they
got comprehensive dental care in addition to the SUD treatment, it
goes up almost threefold. Now I’m sure if you think about that, that
probably doesn’t come as a big surprise to you because you’ve gone in, you’ve
fixed their dental issues. You’ve corrected the pathology. You have put in crowns and you’ve
put in removable prosthesis and if there are empty spaces,
you’ve filled those spaces. So now these people, they can smile. They can have confidence. They have better self-images as to
who they are and what they can do. And they’re probably going to do better
as they go out and they look for jobs and indeed our data says that they do a lot
better if they’ve had comprehensive dental care. So other assessments that we looked at in
the First Step House was drug abstinence. You would hope that with treatment,
SUD treatment, you’re going to get some of these people to get off of
their drugs and then in addition if they get comprehensive dental care,
does that enhance that outcome even more? And the data say yes. So here we have the non-dental
improved like you would hope. The abstinence improves five 138 percent
but if they get comprehensive dental care and significantly improves up to 257 percent. So in this assessment, things look better if you’re giving comprehensive
dental care to these individuals. And the last element that we looked at
in the First Step House was homelessness. There’s a significant incidence of
homelessness in these patients; individuals. So if I’m looking at a non-dental care,
there is an improvement in homelessness in these SUD patients of about 50 percent. But, if they received comprehensive dental care, that reduction in homelessness
goes down to 84 percent. Which you can’t quite tell with the data
as it presented here, is that those numbers in the dental comprehensive dental care,
the homelessness goes down to almost 0. They were almost no — none of those patients, individuals who were getting
comprehensive dental care that were homeless at the end of treatment. So it doesn’t quite reach 100 percent but
there was only like 2 out of the 150 patients or so that got dental care who
still were classified as homeless. So, even homelessness is improved dramatically. So putting all this together, these
assessments, both from Odyssey House as well as from First Step House, what can we conclude? And what might have relevance to those of
you out there working with these clients both in terms of treatment or in terms
of prevention because I think some of the very same factors have relevance as
to whether or not you’re going to prevent or certainly whether or not you’re going to reduce the relapse of
drug abuse in these patients. So the implications. The outcomes for the SUD treatment improve. They improved dramatically. Those four main ones, length
of stay is much higher. The treatment success outcomes
improves dramatically. Employment goes up dramatically if they
have good comprehensive dental care. Abstinence from substance abuse
goes up dramatically and reduction in homelessness is also affected. So when we saw this and I sat down and I started
to write this up for submission to a journal, I mean obviously you want this
kind of information out there. The numbers are really powerful. The outcomes were fairly dramatic and exciting
and so we wanted to submit this for review and then hopefully for publication. But it was clear that in order to do
that, we could just present the outcomes because the reviewer was going to ask
the question, what’s your explanation? Why is happening? And so this is where I stumbled on
to that concept of quality of life. And I have to admit. I really had thought much about quality of
life either in SUD or in dental care prior to putting the two things together;
SUD treatment and dental care. And as I started looking, it became obvious
that the outcomes related to quality of life and I already sort of implied
that to when in my introduction. The quality of life measures have to do with
things such as self-confidence, self-image, ability to work or employment, how you relate to
society, to friends and family and loved ones. It has to do with homelessness and it has to do
with functionality that is, are you functioning and it has to do with things such as nutrition. Do you have healthy life patterns? Do you eat well? All of those things improve by
improving the oral health conditions in those that have major dental issues. So even though I fully admit
we did not specifically look at quality of life assessment measures. This is something we’re doing right now
to see if that hypothesis is correct. It seems fairly compelling that
that’s where you are influenced. That’s what you’re influencing by
improving the dental care issue. You’re creating a better quality
of life for these patients. And if you talk to these patients that came
out of our program, that was the message that they gave to us time
and time and time again. And they are actually examples of
individuals who are contemplating suicide. I mean they were in that stage of their lives. They couldn’t get a job. They had a really poor self-image
and everyone has so deserted them. Everything was despair and they were thinking of
ending it and then fortuitously they were able to become part of our FLOSS program
and it totally turned that around. And just sort of an anecdotal story, I had
gone into our dental clinic and watched some of that interaction between our
dental students and these patients. And as the procedures were being finished and
the patient would get up and was being dismissed by the dental student, they would
walk down the hall to the lobby in front of a mirror and they would stop. They would look in the mirror and
they would give this great big grin and you know what they’re thinking. They’re thinking what a difference and indeed
I’ve got some self-confidence that is popping out of here because of what has happened. So let me just finish up here. Where do we go from here? Is it possible that we have just
identified the tip of the iceberg in looking at comprehensive dental care as part
of substance use disorder treatment? Is it that substance use disorder is an
example of a chronic disease, serious long-term but that is connected with oral
health problems and that by finishing or improving the oral health
pieces that we can then get at the disease itself and improve the outcomes? And we think that that’s a hypothesis
that’s very worth looking at and so we’re starting projects and looking
at resources to ask the question just as we asked comprehensive dental
care improved outcomes for SUD. We think that comprehensive dental care also
will improve outcomes to other chronic diseases such as diabetes, cardiovascular
disease, mental health disorders. And that one probably has a great
significance to substance use disorder because those two are frequently overlapping. Maybe cancers, obesity. Another one that has patterns that
look a lot like substance use disorder and even age-related dementias like
Alzheimer’s; the degenerative disease which has a very high incidence
of serious oral health problems. Could we improve outcomes in
treatment for these kinds of diseases by providing comprehensive dental care. So we think this is the tip of the iceberg. We think it’s a very important tip. We think that we’ve identified a place where
we can start to integrate care with oral health and with substance use disorder
treatment as well as prevention. And we feel fairly confident. By doing so, outcomes are
going to be improved both in the prevention way as
well as any treatment way. So we want to thank you for allowing us to be
part of your education and I’ll just finish off by saying, we here in Utah at the School of
Dentistry are looking for strategies to try to turn our findings into policy. And we’ve already been able to
do that with Medicaid programs. We found a way to integrate substance use
disorder treatment through Medicaid systems by including care, comprehensive dental
care as part of their Medicaid benefits. So it is now being integrated. In other words we have taken
what we learned from FLOSS and we’ve turned it into a Medicaid program. We are now seeing these Medicaid patients
that look just like the FLOSS patients. We’ve seen hundreds of these that
have come through the Medicaid program and fortunately Medicaid has given us
the resources to provide the same kind of dental care was able to do
with the HRSA grant before. Really excited. We think that there’s some real
possibilities for expanding this, both in terms of SUD treatment
as well as in terms of other serious chronic treatments
using programs such as Medicaid and maybe even in the future, Medicare. So, that’s where we are, I’m going to end
it there and open it up for questions.>>Thank you. Thank you Dr. Hanson. We now have a few minutes for questions. If you do have a question
please use the chat feature. So thank you.>>Okay. Well, thank you so much
for your presentation Dr. Hanson. I do want to tell you about our next webinar. Oh, sorry. We do have a question. Sean McMillan, he’s asking you, Dr. Hanson, can
you speak to the impasse on the dental students?>>Sean that’s a really, really good
question because an element of this that I really did have a chance to get
into is trying to utilize resources. And I realized that a lot of what
prevented agencies, SUD treatment agencies, from looking at the dental side, were resources. The resources weren’t there either in
terms of manpower or in terms of Medicaid, Medicare, other sources of funding. And so that was a unique element to what it is
that we put together and our dental students, they did most of the heavy lifting as far as
providing the dental care for these patients. That experience turned out to be
a very, very positive experience. The dental students weren’t
quite sure what to expect when these SUD patients came
to receive dental care. But they soon developed very
good relationships with them. Now, I’ll be honest with you, dental students
are not the fastest operators in the world. But that actually turned
out not to be a liability. It turned out to be an asset because when these
patients came in, they’re used to being brought in on an emergency basis and whoever is
providing the dental care does it quickly and gets them out of there as fast as they can. That was not the case with the dental school. Our students spent time with them. They talked with them. They demonstrated to them I think a sincere
care and sincere interest in their issues, not just her dental issues but
their personal life issues. And so all of that was very rewarding for
both the SUD clients, they learned to love and appreciate what the students have done
for them but also for the dental students. They learned to realize that the
skill sets that are being provided at dental school go a long way towards helping
people in a manner that they never anticipated. I’m sure when it came to dental
school they didn’t ever think, I’m developing a skill that’s going to be
really important in helping to treat drug abuse. Well now they know that the care for oral
health is a comprehensive strategy that needs to be integrated into primary care
as such as taking care of things such as substance use disorder and as I
said, we think it’s got an even broader range of benefits dealing with other
chronic problems as well.>>Awesome. Thank you. We have a couple other questions Dr. Hanson. So from Nancy, she asks have you
considered the possibility that problems and pain could present [inaudible]
substance use disorder?>>Yeah well, I think that the pain is —
so let me just get the question straight. Is Nancy asking whether the pain is
contributing to the substance use disorder?>>Yes. I believe so.>>Okay. Yeah so I think it is. I think there’s a variety of reasons why
individuals abuse these drugs and then as they abuse them, over a period
of time, it turns into an addiction and now there’s other neurobiological
issues that start to play a role in this. And so if you come and you
take care of the pain, in this case oral health pain,
you are doing two things. One is you’re removing one of the
motivations for using the drugs because you’re self-medicating the pain. But two, and those of you who have
had dental pain, severe dental pain where you’re staying awake at night. You can’t concentrate. You know if you get that pain
resolved, all of a sudden your quality of life takes a major step forward. So you’ve improved your outlook
getting rid of the pain. But you’ve also improved it by the relief
that comes from not expecting pain. That you can eat without it hurting. You can do to sleep at night and you can
sleep without having your pain disrupt it. So yeah. I think the pain is a very
critical piece for a variety of reasons.>>Thank you. One more question. Kim asks, what do you believe creates
the biggest damage to one’s teeth. Meth, caffeine drinks?>>I think that, I think that
methamphetamine and I would say this in terms of someone who’s abusing, meaning that they’re
using it on a regular basis, a daily basis. I would say probably the methamphetamine. Methamphetamine is what we call a
sympathomimetic in the jargon of pharmacology and what that means is that it
stimulates the autonomic system. The system in the body that helps to
regulate things such as saliva production and so meth alters the way the
body, the mouth produces saliva. It dries up the mouth. It is a mouth dryer. So anything that drives the mouth is
really going to cause problems for you. It’s not that the meth directly
interacts with the teeth. Like it’s not like a sugar thing. But it just creates an oral environment
where carries is going to form where soft tissues going to
get infected and inflamed and people are going to lose their teeth. So because of that direct action, besides
meth addicts don’t have great hygiene. That’s not a high priority. They’re not caring for their teeth. They’re not getting dental hygiene
and maintaining good oral hygiene. That’s going to be another additive or factor. If I were to compare everything, I would say
meth probably heroin is right up there as well. Heroin can also dry up the mouth and cause some
of the same things that methamphetamine causes.>>Awesome. Thank you. We do have one more question
and then we’ll wrap it up. So Felicia asks, did you have
success with the recurring care and dental hygiene home care for these patients?>>Felicia, that is the question of the hour and
that is really the next step that we have to go to and we intend to look at
that with our Medicaid patients. Now our Medicaid program
gives us sustained access to resources, to ask maintenance questions. So you get them off their drug. You get them through treatment. They’re feeling really good about themselves. They’re getting a job. They’re eating well. They’ve improved their lifestyle in general
and in a year if they don’t pay attention to their teeth, they don’t maintain a good
oral environment and everything just goes back where it was before, are you going
to be right back to square one? And I say that there is a very real
possibility that that’s the case and I think that that potential is a good reason to
argue for programs not only to reverse and correct the oral damage and pathology that
you have in some of these patients but also to have a maintenance program that
allows as part of their SUD maintenance, they’re prevention to include
maintenance for dental care. So, I mean you could integrate the two. Every six months as you’re coming back to sort
of get boosters for SUD, you could also include in that, seeing the dental
hygienist and having maintenance to make sure you keep your oral health
where it’s supposed to be and that quality of life is high and keeping in mind that
the cost for the maintenance is a lot, lot less than having to go in
and trying to reverse pathology that has devastated the oral environment. So great question Felicia.>>Perfect. Thank you so much. Yeah. Thank you Dr. Hanson. Our next webinar is Mamas,
Munchkins, and Methamphetamine – Evidence-Based Prevention Interventions
for Pregnant Women using Stimulants. And this is going to be a webinar presented by
Dr. Marcela Smid on Tuesday, September 10th. Thank you so much for attending
our webinar today. For those of you that have a QR
Code app, you can scan the QR Code or you may click the link in the chat box. You will be provided with a post
evaluation along with an option to complete a thirty day follow up survey. For those who are interested
in our past webinars, we record and post all of
our webinars on our website. All you need to do is click the three bars
to the left of the Mountain Plains navigation to view previous webinars that you can go to our
website which is pttcnetwork/mountain planes. Thank you everyone for attending
today’s webinar. Have a great day.

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