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 pttcnetworkorg/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 mountainplains_pttc@utah

edu 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

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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