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. Author manuscript; available in PMC: 2012 Sep 1.
Published in final edited form as: J Subst Abuse Treat. 2011 Apr 6;41(2):179–185. doi: 10.1016/j.jsat.2011.02.005

Oral health of substance-dependent individuals: Impact of specific substances

Meredith M D’Amore a,*, Debbie M Cheng b,c,d, Nancy R Kressin a,e,f, Judith Jones g, Jeffrey H Samet b,c,h, Michael Winter i, Theresa W Kim b,c, Richard Saitz b,c,j
PMCID: PMC3384491  NIHMSID: NIHMS377258  PMID: 21474269

Abstract

Little is known about how different types of substances affect oral health. Our objective was to examine the respective effects of alcohol, stimulants, opioids, and marijuana on oral health in substance-dependent persons. Using self-reported data from 563 substance-dependent individuals, we found that most reported unsatisfactory oral health, with their most recent dental visit more than 1 year ago. In multivariable logistic regressions, none of the substance types were significantly associated with oral health status. However, opioid use was significantly related to a worse overall oral health rating compared to 1 year ago. These findings highlight the poor oral health of individuals with substance dependence and the need to address declining oral health among opioid users. General health and specialty addiction care providers should be aware of oral health problems among these patients. In addition, engagement into addiction and medical care may be facilitated by addressing oral health concerns.

Keywords: Oral health, Substance dependence, Dental care

1. Introduction

Poor oral health is a common problem among individuals with substance dependence, yet this topic has been largely neglected in the addiction literature (Reece, 2009). Individuals with heavy substance use are at increased risk for poor oral health for a variety of reasons, including limited access to dental care (Johnson, Hearn, & Barker, 2008; Khocht, Schleifer, Janal, & Keller, 2009; Sheridan, Aggleton, & Carson, 2001; ter Horst, Molendijk, Brouwer, & Verhey, 1996), poor dietary (Laslett, Dietze, & Dwyer, 2008; Morio, Marshall, Qian, &Morgan, 2008; Titsas and Ferguson, 2002) and oral hygiene habits (Barbadoro, Lucrezi, Prospero, & Annino, 2008; Friedlander, Marder, Pisegna, & Yagiela, 2003; Morio et al., 2008), negative attitudes about oral health and health care (Robinson, Acquah, & Gibson, 2005), and direct physical effects of the substance on oral health. There are several mechanisms by which drugs can directly affect oral health, including increased xerostomia (dry mouth) due to hyposalivation (lack of salivary flow), poor diet and self-care leading to higher rates of dental caries, enamel erosion, and periodontal disease (Friedlander et al., 2003; Hamamoto and Rhodus, 2009; Morio et al., 2008; Versteeg, Slot, van der Velden, & van der Weijden, 2008).

Prior research suggests that individuals who abuse methamphetamines (Curtis, 2006; Donaldson and Goodchild, 2006; Hamamoto and Rhodus, 2009; Morio et al., 2008; Shetty et al., 2010), alcohol (Araujo, Dermen, Connors, & Ciancio, 2004; Hornecker, Muuss, Ehrenreich, & Mausberg, 2003; Khocht et al., 2009; Manarte, Manso, Souza, Frias-Bulhosa, & Gago, 2009), opioids (Sheedy, 1996; Steinmiller and Greenwald, 2007), marijuana (Versteeg et al., 2008), and cocaine (Brand, Gonggrijp, & Blanksma, 2008) are at increased risk of poor oral health outcomes, including enamel erosion and caries. It is not clear, however, whether these consequences are substance specific or due to substance dependence in general. Suboptimal oral health and periodontal disease are associated with health consequences localized to dental issues, such as tooth loss (Martin, Page, Loeb, & Levi, 2010), and more pervasive physical health problems (Slots, 2003), including cerebrovascular disease (Wu et al., 2000), low birth weight (Cruz et al., 2009; Moliterno, Monteiro, Figueredo, & Fischer, 2005), pulmonary infection (Mojon, 2002), diabetes (Demmer, Jacobs, & Desvarieux, 2008), and potentially cardiovascular disease (Humphrey, Fu, Buckley, Freeman, & Helfand, 2008). Given the deleterious impact of poor oral health on both local and systemic health outcomes, it is critical to identify populations at increased risk in an effort to develop tailored interventions to improve overall health in this population.

Despite its prevalence and consequences, there have been few studies that compare and contrast the oral health of patients who use different substances. Most studies that have examined oral health among substance users are cross-sectional or case studies and have assessed only one type of substance (Araujo et al., 2004; Hornecker et al., 2003; Khocht et al., 2009; Manarte et al., 2009; Morio et al., 2008; Versteeg et al., 2008; Shetty et al., 2010) and include small samples (Araujo et al., 2004; Johnson et al., 2008; Khocht et al., 2009; Morio et al., 2008; Robinson et al., 2005; Sheedy, 1996). Many studies and reviews that have addressed the issue of substance use and oral health were conducted internationally, with little work focused in the United States, where the stigma of substance use and perceptions of and access to treatment for oral health may be different (Barbadoro et al., 2008; Blanksma and Brand, 2004; Cho, Hirsch, & Johnstone, 2005; Johnson et al., 2008; Laslett et al., 2008; Molendijk, Ter Horst, Kasbergen, Truin, & Mulder, 1996; Pilinova, Krutina, Salandova & Pilin, 2003; Reece, 2007; Robinson et al., 2005; Sheridan et al., 2001; ter Horst et al., 1996). Understanding how specific types of substances affect oral health can potentially help target interventions to certain groups at risk. Thus, the purpose of this study is to examine whether substance use, including alcohol, stimulants, opioids, and marijuana, is associated with oral health status among people with substance dependence.

2. Materials and methods

2.1. Design

We analyzed data on self-rated oral health and substance use collected prospectively from participants enrolled in a randomized trial testing the effectiveness of chronic care management in the primary care setting in Boston from September 2006 to September 2008. This study was approved by the Boston University Medical Campus Institutional Review Board. All subjects provided informed consent, and procedures were followed in accordance with the Helsinki Declaration of 1975. A certificate of confidentiality was obtained from the National Institute on Alcohol Abuse and Alcoholism to further protect participants’ privacy. We hypothesized that different types of substances would differentially affect oral health.

2.2. Sample

The sample included 563 men and women who reported using a variety of substances and had enrolled in the Addiction Health Evaluation and Disease Management study. All subjects had current alcohol and/or drug dependence by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria (American Psychiatric Association, 2000) assessed using the Composite International Diagnostic Interview Short form (Gigantesco and Morosini, 2008) and were willing to establish or continue primary medical care at the study location. Participants were included if they reported past 30-day drug use or heavy alcohol use (defined as ≥4 standard drinks for women, ≥5 for men at least twice; or >14 drinks per week for women, >21 drinks per week for men, in an average week in the past month). Approximately 74% of the subjects were recruited from a detoxification center, 9% from ambulatory care/outpatient settings, 1% from the hospital emergency department or inpatient setting, and 16% from other sources. Subjects were at least 18 years of age, spoke English or Spanish, and were without indication of cognitive impairment at screening (assessed using the Mini Mental State Examination score greater than 20; Klein et al., 1985). For this analysis, data were taken from an interview conducted at study entry prior to randomization; thus, any intervention effects would not impact survey responses.

2.3. Measures

2.3.1. Independent variables: Types of substances used

The four main independent variables of interest represented use of a particular type of substance: heavy alcohol (yes/no), stimulants (yes/no), opioids (yes/no), and marijuana (yes/no). All subjects in this study met criteria for substance dependence; however, for this analysis, we are analyzing different types of substance use. Thus, the term substance use is used to refer to these variables. Heavy alcohol use was assessed using the timeline follow-back measure and defined as drinking five or more drinks at least 1 day in the past 30 days (if male) or four or more drinks at least 1 day in the past 30 days (if female; National Institute on Alcohol Abuse and Alcoholism, 2005). Other drug use was assessed using the Addiction Severity Index (McLellan, Luborsky, Woody, & O’Brien, 1980). Stimulant use was defined as using cocaine or amphetamines at least 1 day in the past 30 days. Individuals who used heroin, methadone, or other opioid analgesics, either without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed, at least 1 day in the past 30 days were considered opioid users. Marijuana use was defined as using marijuana or cannabis at least 1 day in the past 30 days.

2.3.2. Dependent variables: Oral health indicators

Our primary outcome was self-reported oral health status (“How would you describe the health of your teeth and gums?”; Jones et al., 2004). Subjects rated this item on a 5-point Likert scale, which was then dichotomized into satisfactory oral health, defined as “excellent,” “very good,” or “good,” versus unsatisfactory, defined as “fair” or “poor” (Cunha-Cruz, Hujoel, & Kressin, 2007; Jones, Spiro, Miller, Garcia, & Kressin, 2002). Four secondary self-reported outcomes related to oral health were also evaluated. Health of teeth and gums compared to 1 year ago was dichotomized as worse, defined as “somewhat” or “much” worse, versus the same, “somewhat” or “much” better. Tooth or gum pain in the past 3 months was dichotomized as pain (“some,” “quite a bit,” or “a great deal”) versus no pain (“little” or “none”). The time since last dentist visit was dichotomized as recent (<1 year ago) versus distant (≥1 year ago, never been to the dentist, or “don’t know”). The number of permanent teeth removed because of tooth decay, gum disease, or infection was dichotomized as 0–5 versus 6 or more (Kapp, Boren, Yun, & LeMaster, 2007) The rationale for this dichotomy was that individuals could have had all four wisdom teeth or bicuspids extracted for orthodontic treatment and still have excellent oral health.

2.4. Covariates

The analyses controlled for sociodemographic and other variables that could affect oral health, including age, gender, education, being a current smoker, race/ethnicity, health insurance, and income. Health status was assessed using one item of a general rating of health on a 5-point Likert scale ranging from “excellent” to “poor”, analyzed as a continuous variable (Ware, Kosinski, & Keller, 1996). In addition, oral health can also be influenced by lifestyle, including dietary and hygiene habits. Individuals in prison (Walsh, Tickle, Milsom, Buchanan, & Zoitopoulos, 2008) or who have experienced homelessness (De Palma and Nordenram, 2005; Gibson et al., 2003) may be at an increased risk for worse oral health due to poorer lifestyle habits and access to care. Thus, we included covariates of ever spending time in prison and recent homelessness, the latter defined as spending at least one night in a shelter or on the street in the last 3 months. Polysubstance use was also included and defined as using two or more of the above substances (heavy alcohol, stimulants, opioids, or marijuana) in the last 30 days.

2.5. Statistical analyses

Descriptive statistics were used to assess the bivariate relationship between subject characteristics and the primary outcome of unsatisfactory oral health. Two sample t tests and chi-square tests were used as appropriate to assess the bivariate associations. We evaluated the association between the types of substances used and each oral health outcome using separate logistic regression models. The multivariable logistic regression models were fit to evaluate the associations between types of substances used and worse oral health outcomes after adjustment for sociodemographic characteristics, health status, and lifestyle variables. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) are reported. To minimize the potential for collinearity, we assessed correlation between pairs of independent variables and covariates to identify pairs of variables that were correlated (i.e., r > .50). Polysubstance use was moderately correlated with stimulant use (r = .66). Polysubstance use was expected to be an important factor and potential confounder; therefore, we fit adjusted models with and without this covariate. Adjustment for polysubstance use attenuated the odds ratios for the main independent variables with oral health status. Thus, we present results controlling for polysubstance use as the final models. All analyses were conducted using two-sided tests and a significance level of .05. Analyses were performed using SAS software (version 9.1; SAS Institute, Cary, NC).

3. Results

The majority of our sample was male (73%), currently smoking (88%), less than 50 years of age (88%; mean age = 38), with an annual income less than $50,000 (74%), had at least a high school education (76%), and had some form of health insurance (79%; Table 1). Almost half were White (47%), 32% Black, 13% Hispanic, and 8% other racial/ethnic background. Most were incarcerated at least once during their lives (78%), and many noted homelessness in the past 3 months (59%). Most reported heavy alcohol (78%), stimulant use (68%), opioid use (67%), and polysubstance use (81%). About half used marijuana in the last month (49%).

Table 1.

Sample characteristics by self-rated oral health status

Characteristic All subjects (n = 563) Subjects with fair or poor
self-rated oral health (n = 335)		 Subjects with good, very good, or excellent
self-rated oral health (n = 228)		 p
Age at baseline, n (%)
  18–34 212 (38) 111 (33) 101 (44) .01
  35–49 283 (50) 174 (52) 109 (48)
  50+   68 (12)   50 (15)   18 (8)
Age, M (SD)   38 (10)   39 (10)   37 (10) <.01
Gender, n (%) male 409 (73) 241 (72) 168 (74) .65
Education, n (%)
  <High school 133 (24)   89 (27)   44 (19) .12
  High school graduate 277 (49) 156 (47) 121 (53)
  >High school 153 (27)   90 (27)   63 (28)
Current smoker 493 (88) 302 (90) 191 (84) .02
Race, n (%)
  White 264 (47) 153 (46) 111 (49) .57
  Black 179 (32) 114 (34)   65 (29)
  Hispanic   75 (13)   43 (13)   32 (14)
  Other   45 (8)   25 (8)   20 (9)
Any health insurance 446 (79) 269 (80) 177 (78) .50
Income, n (%)
  <$20,000 236 (42) 153 (46)   83 (36) .08
  $20,000–$49,999 178 (32)   99 (30)   79 (35)
  $50,000+ 147 (26)   81 (24)   66 (29)
Overall health status, M (SD)a  3.0 (1.0) 3.2 (1.0) 2.7 (1.0) <.01
Ever incarcerated, n (%) yes 438 (78) 254 (76) 184 (81) .14
Homeless, n (%) yes 332 (59) 199 (59) 133 (58) .80
Heavy alcohol use, n (%) yes 440 (78) 270 (81) 170 (75) .09
Stimulant use, n (%) yes 382 (68) 230 (69) 152 (67) .62
Opioid use, n (%) yes 378 (67) 223 (67) 155 (68) .73
Marijuana use, n (%) yes 275 (49) 159 (48) 116 (51) .43
Polysubstance use, n (%) yes 458 (81) 279 (83) 179 (79) .15
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Note. Bold indicates p < .05.

a

Range = 1–5, where 1 is excellent and 5 is poor.

Overall, the majority of the sample reported unsatisfactory oral health (60%), with the most recent dental visit being more than 1 year ago or not able to recall (52%; Table 2). However, most reported the same or better oral health compared with 1 year ago (64%), little or no tooth/gum pain (63%), and having less than six teeth removed (71%).

Table 2.

Self-reported oral health outcomes (n = 563)

Item n (%)
How would you describe the health of your teeth and gums?
  Fair or poor 335 (60)
  Good, very good, or excellent 228 (40)
Compared with 1 year ago, how would you rate the health of your teeth and gums today?
  Somewhat or much worse 201 (36)
  The same, somewhat, or much better 362 (64)
During the past 3 months, how much pain or distress have your teeth or gums caused you?
  Some, quite a bit, or a great deal 209 (37)
  A little bit or none 354 (63)
About how long has it been since you last saw a dentist?
  More than 1 year ago, never, don’t know 292 (52)
  1 year ago or less 271 (48)
How many of your permanent teeth have been removed because of tooth decay or gum disease?
  6 or more 161 (29)
  5 or fewer 387 (71)
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3.1. Primary outcome: Oral health status

In unadjusted analyses, there were no significant associations between heavy alcohol use, stimulant use, opioid use, or marijuana use and unsatisfactory self-rated oral health. The findings were similar in adjusted analyses, where those with heavy alcohol use (AOR = 1.31, 95% CI = 0.79–2.15) and opioid use (AOR = 1.09, 95% CI = 0.66–1.79) had nonsignificant higher odds of unsatisfactory self-reported oral health; those with stimulant use (AOR = 0.85, 95% CI = 0.49–1.47) and marijuana use (AOR = 0.69, 95% CI = 0.45–1.06) had nonsignificant lower odds of unsatisfactory oral health (Table 3). In multivariable models, individuals who were older (AOR = 2.86, 95% CI = 1.41–5.80), currently smoking (AOR = 1.99, 95% CI = 1.13–3.50), and had a worse overall health status rating (AOR = 1.66, 95% CI = 1.37–2.01) had significantly higher odds of unsatisfactory oral health status (not shown).

Table 3.

Adjusted models evaluating the associations between substance use types and oral health outcomes a

Substance
use types		 Oral health outcomes
Unsatisfactory oral
health status		 Worse oral health
compared with
1 year ago		 Tooth/Gum pain >1 year since last dentist
visit		 ≥6 teeth removed
AOR (95% CI) p AOR (95% CI) p AOR (95% CI) p AOR (95% CI) p AOR (95% CI) p
Heavy alcohol use
  Yes vs. No 1.31 (0.79–2.15) .29 1.13 (0.68–1.87) .63 1.02 (0.62–1.67) .95 1.16 (0.71–1.89) .55 0.58 (0.32–1.05) .07
Stimulant use
  Yes vs. No 0.85 (0.49–1.47) .56 0.99 (0.58–1.70) .98 1.15 (0.67–1.97) .60 1.19 (0.71–2.01) .51 1.21 (0.62–2.39) .57
Opioid use
  Yes vs. No 1.09 (0.66–1.79) .74 1.72 (1.04–2.82) .03 1.54 (0.95–2.52) .08 0.92 (0.58–1.48) .74 1.26 (0.73–2.15) .41
Marijuana use
  Yes vs. No 0.69 (0.45–1.06) .09 0.76 (0.50–1.15) .19 0.81 (0.54–1.22) .32 0.77 (0.51–1.16) .22 0.76 (0.46–1.26) .29
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Note. Bold indicates p < .05.

a

Separate models were fit for each outcome, each adjusting for age, education, gender, race/ethnicity, smoking, health insurance, income, health status, lifetime incarceration, homelessness, and polysubstance use.

3.2. Secondary outcomes

In adjusted analyses, opioid use was the only substance significantly related to a worse oral health rating compared with 1 year ago (AOR = 1.72, CI = 1.04–2.82; Table 3). None of the substance types were significantly associated with tooth/gum pain, time since last dental visit, or number of teeth removed. Overall, in adjusted analyses across secondary outcomes, marijuana use was associated with lower odds of worse oral health outcomes, although none of these associations were statistically significant.

4. Discussion

Overall, most of these individuals with substance dependence reported unsatisfactory oral health status, consistent with previous literature (Araujo et al., 2004). Contrary to our hypothesis, we did not detect an association between type of substance and self-reported oral health status. Of note, however, is that the reference group for each comparison is people with substance dependence who do not use the particular substance of interest (e.g., those with heavy alcohol use vs. those without heavy alcohol use but who use other substances), and thus, our findings should not be interpreted or generalized to represent the impact of a particular substance compared with no other substance use. Our results did reveal that opioid use is associated with worse self-rated oral health compared with 1 year ago. This is consistent with research that has found an association between opiate use and poor oral health (Nathwani and Gallagher, 2008; Reece, 2007; Sheedy, 1996; Titsas and Ferguson, 2002). The association could be due to direct effects of opioids, or it could be that people with worsening oral health use opioids for relief (although this seems less likely given the absence of an association between opioid use and dental pain). Of note, however, is that opioid use is reported for the previous 30 days, and worse oral health is compared with 1 year ago. Subjects may be disappointed in their continued substance use, which may have affected their reports of worsening oral health status.

The association between use of methamphetamines or cocaine and poor oral health is well established in the literature (Brand et al., 2008; Curtis, 2006; Donaldson and Goodchild, 2006; Hamamoto and Rhodus, 2009; Shetty et al., 2010). Similarly, research indicates there is an association between alcohol dependence or marijuana use and poor oral health (Araujo et al., 2004; Hornecker et al., 2003; Khocht et al., 2009; Manarte et al., 2009; Versteeg et al., 2008). These findings from other studies are in contrast to ours. One possibility regarding stimulants is that although the prevalence of cocaine use was substantial in our sample, the prevalence of methamphetamine use was not. If more effects on oral health would be seen from the latter, then that could explain the absence of effect. However, one would have expected effects from cocaine itself. Another possible explanation for different findings is that most of the prior studies relied on oral examination to evaluate oral health outcomes. Our findings, that no individual substance type was related to overall oral health status, may be a function of individual subjectivity in the assessment of their oral health. Although methamphetamine use is associated with poor oral health compared with no methamphetamine use, it may not be associated with poor oral health more than other substances in people with dependence. Similarly, given the large percentage of polysubstance use in our sample, we may not have been able to disentangle the effects of specific substances on oral health.

Twenty-nine percent of our sample had six or more teeth removed. This is substantially more than the 8.5% of adults in the general population who have had six or more teeth removed, according to the Behavioral Risk Factor Surveillance Survey data from 2004 (Kapp et al., 2007). This finding confirms other research documenting worse oral health status among substance-dependent populations (Reece, 2009).

Although not the focus of this analysis, we noted that some covariates behaved as we expected, supporting their inclusion in the adjusted models. The association between smoking and worse oral health is not surprising, given the previous literature confirming their correlation (Friedlander et al., 2003; Morio et al., 2008). The persistent association between lower self-rated health status and oral health across several models suggests that oral health may influence physical health or vice versa. A longitudinal study examining health status over time could better determine that causal pathway. Future research should also compare self-reported oral health of this population to the general population to understand the extent to which oral health is worse among individuals with substance dependence.

These findings should be interpreted within the limitations of our analysis. All of our oral health outcomes are self-reported and thus subject to recall and other potential biases; we did not conduct a clinical dental health examination. We believe there is value in understanding patients’ perceptions of their oral health, given that subjective assessment can affect health behaviors (Baker, 2009; Kneckt, Syrjala, & Knuuttila, 1999). For number of teeth removed, which can be considered a less subjective measure, there is evidence that self-report is highly correlated with the number of teeth found missing on clinical examination and thus can be considered reasonably reliable (Pitiphat, Garcia, Douglass, & Joshipura, 2002). We included a measure of recent homelessness in our analysis; however, an estimate of long-term homelessness may have been more appropriate considering its chronic impact on lifestyle, dietary habits, and oral health care. Our definition of substance use was defined within the last 30 days, which may not entirely capture the effects on oral health, given that long-term exposure of a particular substance would have more of an impact on these outcomes. Given our reference group in adjusted analyses, we are not able to assess the independent effects of a particular substance compared with people who did not use any substances. Instead, our results indicate the effects of a substance on oral health, above and beyond the effects of other substances. Finally, we do not have data to compare to non-substance-using populations, and thus, it is difficult to tease out the effects of substance use and other sociodemographic characteristics. We attempted to do so in our adjusted model, controlling for age, education, gender, race/ethnicity, smoking, health insurance, income, health status, lifetime incarceration, homelessness, and polysubstance use.

Despite these limitations, this study is among the first to assess the differential effects of varying types of substance use on self-rated oral health outcomes. Our findings suggest that addiction treatment providers, as well as medical and dental clinicians, should consider dental and addiction problems as associated comorbidities, requiring the development of treatment plans that address both substance use and potential oral health problems. These results suggest that type of substance had little effect on oral health outcomes. However, the overall poor rating of oral health in our sample indicates that the health of teeth and gums is a significant issue among individuals who use alcohol and/or drugs, in general. Thus, interventions for poor oral health could be tailored toward this population.

Despite the association between substance use and oral health and national recommendations for improving oral health among such vulnerable populations (Department of Health and Human Services, 2000), few interventions have been targeted to individuals with substance dependence. One intervention aimed at improving knowledge, attitudes, and behavior of individuals with alcohol dependence found that the intervention group who attended a lecture had significant improvement in oral health behaviors after 1 year, including frequency of tooth brushing (Barbadoro et al., 2008). Although conducted in Italy, this study has implications for rehabilitation programs in the United States, where such educational workshops can be incorporated into treatment. Clinicians should pay particular attention to oral health among opioid users. Given our findings, and the correlation between oral and general health status, oral health warrants increased attention and public health efforts among substance users. In addition, general health and specialty addiction care providers should be aware of oral health problems among patients with substance dependence. Finally, engagement into addiction and medical care, often a challenge in this population, may be facilitated by addressing oral health concerns.

Acknowledgments

This project was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Grant R01AA010870, National Institute on Drug Abuse (NIDA) Grant R01DA010019, and National Center for Research Resources (NCRR) Grant UL1RR025771.

Dr. Jones is supported by K24DE018211.

Footnotes

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAAA, NIDA, NCRR, or the National Institutes of Health.

No authors have identified any financial conflicts of interest for this study.

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