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

Behind every smile lies a story. For dental hygienists, the mouth often reveals information that patients may never share. Dental professionals may encounter patients with substance use disorders, which uniquely positions them for early detection and intervention.

Oral manifestations of substance use may appear before other health-care providers recognize them. A study found that 20.6% of adult patients at a dental school clinic reported recent problematic alcohol or illicit drug use, suggesting that dental settings are valuable points for identifying at-risk individuals.¹ Dental professionals can stay proactive by using resources such as the Digital Drug Handbook by MedAssent DDS, which offers information on medications with addictive potential.

Here we’ll help dental hygienists recognize oral manifestations of substance use and how to practice compassionate, evidence-based intervention strategies. Through clinical scenarios, we’ll explore how addiction touches people from every background—because it doesn’t discriminate by zip code, profession, or status.

When success takes a toll: Alcohol abuse and oral health

Clinical scenario: James, 53, the CFO of a regional insurance company, regularly schedules his biannual cleaning appointments. During the past year, he frequently reschedules afternoon appointments and arrives at morning visits with alcohol-scented breath masked by mouthwash. He often shares stories of clumsy injuries and minor accidents and has begun requesting pain medications at levels that seem inconsistent with clinical findings. Despite a calm demeanor, there's a growing mismatch between his polished appearance and behavioral red flags.

Clinical signs

Alcohol abuse leaves distinctive markers in the oral cavity that vigilant hygienists should recognize:

• Mucosal changes: Chronic alcohol consumption dehydrates oral mucosa, presenting as atrophic changes and decreased salivary flow.² James's tissues appear increasingly dry despite his reported water intake.
• Periodontal disease: High alcohol consumption correlates with 2.15 times higher risk of periodontitis, particularly among females.³ Despite James's meticulous flossing routine, his periodontal measurements show progressive deterioration.
• Cancer risk: Alcohol represents a significant risk factor for oral cancer, particularly when combined with tobacco use.⁴ The risk increases proportionally with consumption volume.
• Dental trauma: Alcohol’s impact on motor coordination and reaction time increases the risk of falls and other physical accidents that can result in oral trauma. While James attributes his growing number of fractured teeth to stress-related clenching, the pattern and context of his injuries suggest that intoxication-related accidents may be a more likely explanation.

Beyond the surface: Methamphetamine use and meth mouth

Clinical scenario: Elijah, 27, once meticulous about his appearance, returns after three years visibly anxious and distracted. He admits to long periods of poor hygiene and speaks rapidly, interrupting himself and glancing around the room. He shares concerns about dry mouth but avoids eye contact and asks repeatedly if the exam will hurt.

Clinical signs

Meth mouth represents one of the most recognizable patterns of substance-related dental disease:

• Rampant caries: It typically presents as distinctive smooth-surface caries, particularly affecting the facial and cervical areas of teeth, as well as anterior teeth.⁵
• Pattern of decay: A study from UCLA identified characteristic patterns of dental caries in methamphetamine users. Posterior teeth were the most commonly affected, especially on the occlusal surfaces. The researchers also found that men were more likely to have untreated caries on mandibular teeth, while women had a significantly higher rate of anterior caries.⁶
• Xerostomia: Severe dry mouth results from the sympathomimetic effects of methamphetamine, contributing significantly to caries development.⁵

Bruxism and wear:

•  Excessive tooth grinding may be evident as methamphetamine stimulates the central nervous system, leading to attrition patterns and possible temporomandibular disorders.⁷

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

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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. https://ostrowonline.usc.edu/medications-that-cause-dry-mouth/
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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. https://www.ada.org/resources/practice/practice-management/documentation-patient-records
20.  ADHA code of ethics. American Dental Hygienists’ Association. 2019. https://www.adha.org/ADHA-Code-of-Ethics
21. SAMHSA’s national helpline. Substance Abuse and Mental Health Services Administration. 2020. https://www.samhsa.gov/find-help/national-helpline