Dental Care Represents Huge Gap in Recovery Services

This essay appeared in Facing Addiction, thanks to Laszlo Jaress.

Recovery means leaving destructive substances behind. However, some habits leave lasting marks.

Dental care is an overlooked but critical recovery service. Sustained recovery can erase track marks, jaundice, and abscesses. Teeth, however, don’t rebound easily from regular exposure to substances like alcohol or heroin.

Oral health may be the key to help people with substance use disorder reenter society. But many struggle to make dental care a priority: it’s a complex problem, complicated by factors that hinder access to dental care.

Most treatment for addiction emphasizes intervention, not long term support like dental care. Substance use disorder is most commonly treated in its acute stages. Prevention focuses on overdose prevention, not whole person care. In the current model, any care beyond immediate, life-threatening issues is not well defined.

Jessie Glenn, a board member at Oregon Health and Science University’s Richmond Family Medicine Clinic in Portland, Oregon, said, “Dental care is one of the hardest things for low income people to access and people struggling with addiction often need it the most. Dental care needs to be a priority. People can die of abscesses. There are obviously a host of issues that plague people with substance abuse issues, but prioritizing physical health, safety, and the promise of support is a good starting place.”

The Richmond location is a safety net clinic that serves a high-risk, low income population. Most patients, Glenn says, pay very low fees for services. Many services are free. The goal is not only providing affordable dental care, but also changing the healthcare model to patient centered care, which includes oral and dental health.

For people in recovery, staying sober is the priority. Dental care often comes last on the recovery to-do list because it is too expensive, hard to find, or simply not as important as other needs, like paying rent or going back to school.

Broken teeth and advanced tooth decay are commonly reported dental issues for people with substance use problems. Substances like heroin, meth, and cocaine are cut with corrosive ingredients that actually melt the enamel off your teeth, leaving blackened stumps. Smoking crack can make your teeth brittle, and stain them as yellow as a wolf’s.

With good insurance, some people repair their teeth with little out-of-pocket cost: one person, after a decade of drug use, was able to get crowns on all his top teeth a decade ago. He estimated that the crowns cost $2,000 each. The entire procedure was $28,000. Now, those crowns have started to show signs of wear, so he’s thinking of switching to implants — which will cost thousands more.

For many, undergoing the treatment process is prohibitive for people who can’t have opioid painkillers. Invasive procedures like fillings, crowns, bone grafts, and implants require pain management. For some people, refusing medication is a principle: they refuse any mind-altering “solids, liquids, or gases.” For others, it’s a precaution against reawakening their addiction. They’ll avoid anything that may put their recovery at risk, including care that will improve life in the long run.

Yet, the consequences of not repairing substance-related tooth damage are serious, too. In addition to ongoing oral health problems, a person with severely damaged teeth misses out on social benefits, too. A 2012 study showed a strong correlation between a healthy-looking smile and better social status. 73 percent of Americans say they’re “more likely to trust someone with a nice smile than someone with a good job, outfit, or car.” The same study showed Americans perceive people with straight teeth as 45 percent more likely to get a job, when competing with someone who has a similar skill set and experience but crooked teeth.

Feelings of shame were linked, in another recent study, to depression and addiction. Severely damaged teeth, or an appearance that evokes drug use, can lower self esteem and actually lead to a relapse.

Dr. Beverlee Cutler, Dental Director at OHSU’s Russell Street Clinic, said, “The decayed or damaged teeth are a visible identifier of past bad choices. The person may feel shame or grief. They might have had braces or expensive dental work in the past, and feel embarrassed at having to get teeth pulled,” Cutler said. “We see a lot of the classic ‘meth mouth,’ with black decay at the gum line. You know immediately from the appearance and health of the teeth that there’s a history of substance abuse.”

Cutler said, “To repair years of damage, the treatment plan is going to mean lots of appointments. We don’t just fill holes. The first cleaning will take four visits. After that, it’s one appointment for temporary fillings, and then another four to six appointments for permanent fillings, or a partial or bridge. The person must follow through and do their part. They have to be willing to work on their oral hygiene every day, just like they work on their recovery.”

Every person who’d undergone extensive dental repairs said that pain is worth it. The promise of a new life, and a chance to start over, they said, was priceless. With luck, and persistence, the investment in a new smile — -and their hard-won sobriety — -will last a lifetime.

Cutler said, “Our approach is like the 12 Steps. Getting people in the chair is the first step. Until someone’s ready to take ownership, the best dentist in the world can’t help them.” That first step is often the biggest, for people in recovery. Yet, for those who stay the course and have access to dental care, the rewards can be significant.

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