Substance abuse and oral health: Recognizing the signs behind the smile

When healing turns to harm: Opioid abuse

Clinical scenario: Amber, 26, presents for evaluation of ongoing jaw pain she attributes to a bad extraction performed six months ago at another office. During the intake, she specifically requests a refill for hydrocodone, explaining that it’s “the only thing that works” and that she’s “allergic” to ibuprofen and acetaminophen. She displays an unusually detailed knowledge of various opioid medications, discussing formulations in detail. A review of her medical records—after obtaining consent—shows repeated visits to different providers for dental pain, each time citing dental pain and receiving prescriptions for opioid pain relievers.

Clinical signs

Prescription and illicit opioids present unique challenges in the dental setting:

• Caries pattern: While less visually distinctive than methamphetamine-associated decay, opioid users often exhibit significantly poor oral health marked by high rates of missing and decayed teeth and periodontitis.⁸
• Gingival and mucosal issues: Immunosuppression from chronic opioid use can lead to increased susceptibility to fungal infections and delayed healing.⁹
• Pain perception: Paradoxically, chronic opioid users may exhibit hyperalgesia, presenting with increased sensitivity to pain despite analgesic use.¹⁰

The PTA president’s secret: Benzodiazepine abuse

Clinical scenario: Sarah, 38, is a PTA president and frequent volunteer. With three children in elementary school, she often jokes about needing “mommy’s little helpers” to keep everything under control. Recently, there’s been a concerning pattern: Sarah frequently arrives late to her appointments, sometimes appearing confused about the time or reason for her visit. Her speech is occasionally slurred, and you observe subtle issues with her coordination. Additionally, she mentions frequent falls at home, presents with repeated oral trauma, and has multiple prescriptions from different providers.

Clinical signs

Benzodiazepines, commonly prescribed for anxiety and sleep disorders, present several oral health implications when misused:

• Xerostomia: Chronic benzodiazepine use causes significant reduction in salivary flow, contributing to increased caries risk, periodontal disease, and oral infections.¹¹
• Oral candidiasis: The immunosuppressive effects of benzodiazepines, combined with xerostomia, create favorable conditions for opportunistic fungal infections, particularly candidiasis.¹²

The recreational user: Cannabis use

Clinical scenario: Alexis, 29, works in a state where cannabis use is legal and openly shares that she uses it regularly to unwind. At recent appointments, you’ve noticed a characteristic cannabis odor lingering during her visits. She reports persistent dry mouth that cannot be attributed to any prescribed medications and mentions feeling the need to snack frequently between meals to curb her appetite. Clinically, despite maintaining good brushing habits, she is showing an increasing number of interproximal caries, likely exacerbated by the frequent exposure to fermentable carbohydrates and the chronic xerostomia.

Clinical signs

With increasing legalization, cannabis-related oral findings are becoming more common:

• Xerostomia: Cannabis use reduces salivary flow, potentially increasing caries risk and periodontal disease.¹³
• Stomatitis: Cannabis smoking is associated with chronic inflammation of the oral mucosa and increased prevalence of leukoplakia.¹⁴
• Periodontal effects: Studies have shown higher rates of periodontal disease among regular cannabis users.¹⁵
• Oral cancer: Though less conclusive than with alcohol and tobacco, some research suggests a potential association between chronic cannabis use and oral malignancies.¹³

The weekend habit: Cocaine use

Clinical scenario: David, 32, works in finance and arrives for evaluation of recent oral discomfort. During the appointment, he reports frequent nosebleeds and episodes of unexplained nasal congestion that he attributes to seasonal allergies, although the timing doesn’t align with typical patterns. He also mentions occasional facial numbness and vague pain around his upper jaw and cheek area. On examination, you notice significant gingival recession in the anterior maxilla and identify a concerning palatal lesion—a small perforation—which David was unaware of until you point it out. He denies any history of trauma or known medical conditions that would explain these findings.

Clinical signs

Cocaine presents distinctive oral manifestations:

• Gingival lesions: Topical application to gingiva causes characteristic ulceration and recession, particularly in anterior areas.¹⁶
• Palatal perforation: Long-term intranasal cocaine use can lead to midline perforation of the hard palate due to vasoconstriction and subsequent necrosis.¹⁶
• Excessive wear: Bruxism associated with stimulant use may present as atypical wear patterns.¹⁷
• Oral cancer: Despite the prevalence of lesions due to cocaine use, it remains important to biopsy the lesion, as there is preliminary evidence of the potential carcinogenic effect of cocaine on head and neck cancers.¹⁸ Continue to follow up on any perioral or cheek numbness.

Dental professional responsibilities and intervention

As health-care providers, dental hygienists have ethical responsibilities when substance abuse is suspected:

• Documentation: Thoroughly document all clinical findings and patient interactions in a factual, nonjudgmental manner.¹⁹
• Communication: Develop rapport with the patient and communicate findings to the dentist. When speaking to the patient, use professional, nonstigmatizing language referred to as motivational interviewing communication.²⁰
• Knowledge of resources: Be aware of local substance use treatment resources that the dentist may choose to provide to patients. Familiarity with resources such as the SAMHSA (Substance Abuse and Mental Health Adminstration) helpline can be valuable information to offer the dentist when discussing patient care.²¹
• Supporting patient education: When directed by the dentist, provide education on oral health impacts of various substances, focusing on health consequences rather than personal judgments. Education should remain within the scope of dental hygiene practice and support the dentist’s overall treatment plan.

The mouth often reveals what patients try to hide. Dental hygienists play a vital role in recognizing signs of substance use through oral health patterns. With careful observation, thorough documentation, and appropriate intervention, hygienists can help patients beyond just dental care. Early identification and referral can open the door to recovery. Addiction doesn’t discriminate—it can affect anyone in your chair. Your attention to detail could be the first step in someone’s path to healing.

References

1. Ilgen M, Edwards P, Kleinberg F, Bohnert ASB, Barry K, Blow FC. The prevalence of substance use among patients at a dental school clinic in Michigan. JADA. 2021;143(8):890-896.
2. Khairnar MR, Wadgave U, Khairnar SM. Effect of alcoholism on oral health: a review. J Alcohol Drug Depend. 2017;5:266.
3. Wang J, Lv J, Wang W, Jiang X. Alcohol consumption and risk of periodontitis: a meta-analysis. J Clin Periodontol. 2016;43:572-583. doi:10.1111/jcpe.12556
4. Hashibe M, Brennan P, Chuang SC, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev. 2009;18(2):541-550. doi:10.1158/1055-9965.EPI-08-0347
5. Hamamoto DT, Rhodus NL. Methamphetamine abuse and dentistry. Oral Dis. 2009;15(1):27-37. doi:10.1111/j.1601-0825.2008.01459.x
6. Shetty V, Harrell L, Murphy DA, et al. Dental disease patterns in methamphetamine users: findings in a large urban sample. J Am Dent Assoc. 2015;146(12):875-885. doi:10.1016/j.adaj.2015.09.012
7. Rommel N, Rohleder NH, Koerdt S, et al. Sympathomimetic effects of chronic methamphetamine abuse on oral health: a cross-sectional study. BMC Oral Health. 2016;16(1):59. doi:10.1186/s12903-016-0218-8
8. Smeda M, Knogl C, Müller K, et al. Impact of opioid abuse on oral health: a retrospective cohort study. Front Oral Health. 2025;6:1483406. doi:10.3389/froh.2025.1483406
9. Berthézène CD, Rabiller L, Jourdan G, Cousin B, Pénicaud L, Casteilla L, Lorsignol A. Tissue regeneration: the dark side of opioids. Int J Molec Sci. 2021;22(14):7336. doi:10.3390/ijms22147336
10. Brush DE. Complications of long-term opioid therapy for management of chronic pain: the paradox of opioid-induced hyperalgesia. J Med Toxicol. 2012;8(4):387-392. doi:10.1007/s13181-012-0260-0
11. Mulligan R, Suarez-Durall P, Han P. Dry mouth: Medications and their effects on saliva. Herman Ostrow School of Dentistry of USC. October 9, 2019. 
12. Tamai R, Kiyoura Y. Candida infections: the role of saliva in oral health-a narrative review. Microorganisms. 2025;13(4):717. doi:10.3390/microorganisms13040717
13. Bellocchio L, Inchingolo AD, Inchingolo AM, et al. Cannabinoids Ddugs and oral health–from recreational side-effects to medicinal purposes: a systematic review. Int J Mol Sci. 2021;22(15):8329. doi:10.3390/ijms22158329
14. Darling MR, Arendorf TM. Effects of cannabis smoking on oral soft tissues. Community Dent Oral Epidemiol. 1993;21(2):78-81. doi:10.1111/j.1600-0528.1993.tb00725.x
15. Shariff JA, Ahluwalia KP, Papapanou PN. Relationship between frequent recreational cannabis (marijuana and hashish) use and periodontitis in adults in the United States: National Health and Nutrition Examination survey. 2011 to 2012. J Periodontol. 2017;88(3):273-280. doi:10.1902/jop.2016.160370
16. Brand H, Gonggrijp S, Blanksma C. Cocaine and oral health. Br Dent J. 2008;204:365-369 doi:10.1038/sj.bdj.2008.244
17. Melo CAA, Guimarães HRG, Medeiros RCF, Souza GCA, Santos PBDD, Tôrres ACSP. Oral changes in cocaine abusers: an integrative review. Braz J Otorhinolaryngol. 2022;88(4):633-641. doi:10.1016/j.bjorl.2021.04.011
18. Zhang M, Chen C, Li G, et al. Cocaine use and head and neck cancer risk: a pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Med. 2024;13(3):e7019. doi:10.1002/cam4.7019
19. Documentation/patient records. American Dental Association. Accessed April 29, 2025. 
20.  ADHA code of ethics. American Dental Hygienists’ Association. 2019. 
21. SAMHSA’s national helpline. Substance Abuse and Mental Health Services Administration. 2020.