Glen Hanson, DDS, PhD, Vice Dean, School of Dentistry at the University of Utah talks about how dental care can help people with substance abuse problems get back on their feet.
Interview conducted by Ivanhoe Broadcast News in May 2019.
Tell us a little bit about the floss program.
HANSON: My research background is pharmacology, the study of drugs. I also have a background in dentistry. My area of expertise as it relates to my research, is in the drug abuse field. For a long time I have thought there’s a connection between drug abuse and oral health because patients or individuals who have substance use disorder commonly have major dental problems. I have wondered what is the explanation for this co-occurrence and why is it that these two disease processes interact with each other. It so happens that six years ago we started a new dental school here at the University of Utah and I became involved with this effort. Consequently, I had a unique chance to bring to the new School of Dentistry some of my research interests in the drug abuse field. There created an opportunity to apply for a grant from the federal government which was to examine the interaction between issues of drug abuse and its treatment and oral health pathology. The objective of this grant was to train workforces associated with both of these disciplines in order to improve treatment outcomes. I felt that this grant could be an opportunity to address my questions regarding the linkage between Substance Use Disorder (SUD) and oral health problems. In particular, if you care for oral health in a comprehensive manner, does this influence how SUD persons respond to their drug abuse disorder treatment? We referred to this grant with the acronym FLOSS. It basically examines the importance of oral health for individuals who have substance abuse problems. While FLOSS was a grant to train workforces we were also watching and assessing outcomes in order to determine the interactions between these two treatment efforts (i.e., dental care and SUD treatment). About halfway through the grant our partners, from Odyssey House and First Step house, which are well-established providers of treatment for SUD patients, came to us to share a dramatic observation. They found that those SUD patients receiving comprehensive dental care did much better in their SUD treatment outcomes: specifically, they observed that the length of stay for these SUD patients, which is a fairly good indicator as to the likelihood of success of treatment, was 2 to 3-times longer: I mean, it was approximately 100 days average for patients just receiving SUD treatment but not comprehensive dental care compared to almost 300 days for those who also received the dental care. It was something you couldn’t miss. It wasn’t subtle. But it was huge. Needless to say we were all excited about this finding and we decided to take a closer look. We found similar effects in both First Step House and in Odyssey House. This is significant because Odyssey House is set up a little different from First Step. First Step is all male clients, many of whom were referred by the criminal justice system. Thus, drug courts sent them to First Step as well as Odyssey; however, Odyssey cared for both male and female. And there was more of a family support system in Odyssey House. The treatment outcomes for the SUD in both houses were very similar and the gender did not seem to matter. In addition, it didn’t seem to matter what drug they were using. And half of our patients were heroin users (heroin users are notoriously difficult to treat). Heroin users tend to have major relapse problems, yet they were benefited by comprehensive dental care just like methamphetamine users or alcoholics or marijuana-dependent patients. Thus the drug of abuse didn’t seem to matter either. We were treating patients between 20 and 50 years of age; young or older, they all responded similarly. The only variable that correlated with these improved outcomes was if comprehensive dental care was part of the treatment.
How many patients do you think you treated through this program?
HANSON: We did about 300. So it’s a fairly large study and we compared to our control group which was about 1,000 clients. We can confidently say that the comparison was very profound and the statistical differences were highly significant. The effect was a extremely powerful.
Will you do further studies to or more structured studies to prove this even further?
HANSON: The research structure is always a problem when you do a retrospective study. And that’s what this was. We were confident that there could be an interaction between the SUD treatment and the comprehensive oral health care. I thought there would be some benefit in doing comprehensive dental care like a 20% improvement in the SUD conditions. I certainly did not expect 200% improvement. The size and the power of the interaction of treatment was very impressive. We are continuing to examine our SUD patients and their assessments to see if we can learn more about the connection between SUD and dental care and the potential for improving treatment strategies for SUD management. The agencies who provided the support for SUD care, such as Medicaid, want to know if including oral health care as part of their management is worth an extra investment? So, they are watching the interactive effects closely. The assessments are very good and well-defined. One of the things that did happen though by accident, was we allowed the agencies to decide how to identify their own patients. We told them that we wanted patients in our FLOSS study who had significant oral health problems and we were not interested in patients who just wanted to get a cleaning and a fluoride-we didn’t think that would really tell us very much. We requested SUD patients with major oral health issues. First Step House allowed their patients to self-select. And they actually did a pretty good job. The ones that had the major problems were the ones who tended to volunteer for dental care. They were self-motivated to volunteer for this. However, self-selections can be problematic when you’re trying to do comparisons between control and treated groups because if participants are self-selected into the treated group, then you may have introduced an undetermined dependent variable that confounds the interpretation.
HANSON: Fortunately for us, the Odyssey House approach for group selection was different. Odyssey used a more traditional research format for group makeup. They had caseworkers who were able to triage and look into the mouths of their patients to determine the presence of major oral health issues. Of those SUD patients interested in participating in the study and with major dental problems they identified approximately 300 SUD treatment clients. They arbitrarily selected approximately half of them to receive comprehensive dental care to compare to the other half that didn’t. With the Odyssey House, the control and treated groups looked very similar with the only significant difference being the inclusion of dental care.
This arrangement turned out to be very fortuitous because in real life the SUD patients will need to agree to have their oral health problems address, which is most closely modeled by the self-select approached used by First Step House. For example, you’re not going to force your SUD patients to receive dental care as part of their SUD management if they are not interested. Whereas the scientific questions are better addressed when you employ the Odyssey House double-blinded, random-selected group model so you can control for variables that might confound your conclusions.
Why do you think this worked?
HANSON: We examined employment outcomes and found those who received comprehensive dental care were two to three times more likely to be employed when they left treatment than those who didn’t. We looked at abstinence from drug use. And that also improved by two to three fold in those that got dental care. We looked at homelessness. And homelessness almost completely disappeared in that group who received the comprehensive dental care. So these other factors all pointed to the same thing: the treatment for SUD is better and these individuals are going to be better prepared to go out and to survive. So with those factors in place, we started to look for a cause.
HANSON: What’s going on here and why is this interaction so powerful? One of the things that popped out as a possibility was what they call Quality of Life. There is a fairly robust literature testing the impact of Quality of Life on medical conditions. That is if you address medical problems, improving Quality of Life tends to improve the treatment outcomes of chronic diseases. Thus, with cancer, if you give patients a good Quality of Life while you’re dealing with the cancer the recovery from the disease is improved and the progress of the disease is hindered. This also works for substance use disorder. If you take care of medical needs and give them a better Quality of Life, they do better in the treatment for the drug problem. We believe that improvement of the dental Quality of Life contributes to overall Quality of Life. If you think about it, the mouth is a critical part of how you present yourself when you meet somebody. If you have a really great smile, a really nice looking mouth, things are going to happen. Good things will happen to you both in terms of getting a job and presenting yourself. When you look in the mirror, you have a better feeling about who you are, how you relate to other people, your family, your friends, your community. It also improves functions such as eating. With a healthy mouth you can eat foods that you really like to eat and which are nutritious. If you’re into eating food, this could be a big piece of Quality of Life. Some of those who have drug abuse problems have pain 24/7. They have infections, they have abscesses, they have teeth that need to be extracted or have already been removed. They can be young 20 – 30-year-olds who have few or no teeth. They’re walking around with their hands covering their mouth and looking down at the ground. They won’t look in your eyes, or at your face. If you examine the factors that define Quality of Life and you’re doing an assessment, what sorts of questions do we ask? We ask questions like how do you feel about yourself? We ask questions about employment, such as how is your job? Can you get a job? Is it reinforcing to have a job—does it make you feel good about yourself? How do you relate to other people? How is your social interaction? How is the mouth functioning, can you eat? Can you eat food you enjoy? Can you eat healthy foods that are going give you nutrition? These are all Quality of Life elements. The very factors that we consider as part of our Quality of Life assessment are the things dramatically improved by integrating comprehensive dental care with SUD treatment. Consequently, we believe by including comprehensive dental care we are dramatically improving Quality of Life because of oral health care interventions which in turn improves SUD treatment outcomes.
What will you do with this information now? How do you forward that?
HANSON: We have already done several things with our findings. One is a very practical outcome because our FLOSS grant ended September 2018. Our dental students loved working on these patients. Interestingly they were a little timid when we first announced we’re going to bring in patients who were being treated for drug abuse problems; however, with experience they came to appreciate that these are people with major, medical, emotional issues that they’re trying to address, not to mention these SUD patients have some very interesting dentistry to do- that was another benefit. Frankly, while our dental students aren’t the fastest operators in the world, the students who worked on these patients were very experienced and technique competent. For most of these SUD patients, their previous dental experiences were only emergency treatment. They had a pain, they had an ache, they had an abscess and they would go to an emergency room and in a matter of minutes their teeth were extracted: the pain and infection were gone after which the SUD patient often was encouraged to leave the emergency room promptly. These patients often explained that they felt that they are a charity case and the provider didn’t really want to get involved, especially because the patient often had little or no money to pay for the dental services. In contrast, the dental students really wanted to be doing the dentistry and interacting with these patients. They got to know each other. There was some interesting bonding that took place. When students heard the FLOSS program was coming to an end, they were upset thinking we had this great program and it was really working well, and now it’s going away. Especially the younger students who didn’t have a chance to participate in FLOSS were concerned. I was frequently approached by the younger students and asked, are we going to get to see FLOSS patients like this when we get into the clinic? They would hear the upperclassmen talk about it and what a positive opportunity it had been. We wanted to continue the program, but we also wanted it to have an impact because we’d discovered something important. We started to appreciate the potential social implication if we could institutionalize integration of dental care with treatment for substance use disorder,. These SUD patients can be very, very expensive persons for society to care for. They oftentimes end up in correctional institutions which can cost up to $20-40,000 a year. If they are parents, they often have their children taken away and placed into some very costly social programs. These SUD patients don’t work, so they do not contribute to the system. They come to our emergency rooms because they repeatedly have emergencies, overdoses, infections, and disease. They’re costing us considerable money for many different reasons. If we can improve the SUD treatment outcomes two- to three-fold by investing $1,200 – 1,500 to take care of their oral health needs and eliminate on the other end, the criminal justice expenses, and help them get jobs and actually contribute to, instead of pull from, the system. If we can take their children out of the social services and allow them to have a family, over a life-time of an SUD patient, we can be saving the community literally hundreds of thousands of dollars.
Is this something that you get in the legislature for?
HANSON: We went to the Utah legislature in 2018 to share our findings. We explained what happens when comprehensive dental care is provided to patients who are receiving treatment for SUD. As you can imagine, it was pretty obvious. Even someone without a science background, who didn’t know how to read research papers, could appreciate that there was an enormous beneficial effect. It did not take a lot to convince them of the fiscal benefits of getting these people out of that SUD relapse pattern that typically occurs. So, they understood and accepted what we were telling them. They voted almost unanimously to extend comprehensive dental care to patients who were receiving treatment for substance use disorder and were part of the Medicaid program- in other words it was an expansion of Medicaid benefits specifically targeting SUD patients. Many of these patients were homeless, unemployed and had serious drug problems in addition to mental health issues. Because these persons often hung out in high-crime downtown areas, where the homeless shelters and food kitchens often were located, the police and the politicians and the legislatures were anxious to help these people; this included putting them into the Medicaid system, with access to medical care. We were able to also convince them as part of this Medicaid program to provide comprehensive dental care like the FLOSS program. We feel confident that we will enjoy the same improvement in SUD management as we found with the FLOSS patients.
Is this Medicaid expanded from the legislature?
HANSON: It’s not the traditional Medicaid expansion program, but it is a special waiver request for federal support to cover the dental care.
So the program is continuing but under different permission?
HANSON: Through the Medicaid. But we’re able to provide exactly the same comprehensive care that we did with the FLOSS program.
When did start?
HANSON: It started in March. It had to be approved by the federal government. Anytime you do an expansion of Medicaid it is a state-Federal partnership. So the state agrees and, the School of Dentistry helps cover the state portion of the program. Because of the novelty of this Medicaid expansion request, Medicaid sent their people here to ask us about details as to why this arrangement works and how we will care for these patients. They’d never seen a proposal like this before. They spent an afternoon with us. And we talked about the study. And we took them into our dental clinic to talk to our SUD patients and dental students. They were very excited and approved the program. We have educated other states to see if they might be interested in this approach as well. And we’re assessing. We will assess this Medicaid program to make sure that it looks like the FLOSS in terms of the outcome. We have no hesitation in predicting that the outcomes will be FLOSS-like.
END OF INTERVIEW
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