| Abstract|| |
Background: The term substance is usually used to address psychoactive/psychotropic drugs which include both licit and illicit drugs. These substances have varied consequences, including long-term and short-term effects, which include sensations post-consumption. Aim: To determine patterns of substance use and short-term oral health effects among substance users. Materials and Methods: A self-administered questionnaire-based study was conducted on the inmates of drug deaddiction and rehabilitation centres in Bhubaneswar city. Results: All the subjects were males and majority (60.6%) were polydrug users. Alcohol (87.3%) was the most commonly used substance, followed by ganja (57%), bhang (35.3%) and brown sugar (33%). A wide range of oral health sensations like dryness of mouth, taste change, numbness in mouth, feeling like chewing something, loose teeth and stammering/difficulty in speaking were found to be significantly associated with substance use. The age of start of substance use (P < 0.0001), socioeconomic status (P = 0.026) and marital status (P < 0.0001) were significantly associated with the pattern of substance use. About 37.6% of inmates felt that they had very good oral health before starting drug use, while only 15.4% described their oral health as very good at present. Having no oral health problem was the most common reason for not visiting a dentist, followed by ignorant attitude towards oral health. Conclusion: A wide range of oral health sensations were found to be caused due to substance use. Understanding of oral health sensations can aid practitioners detect and report cases of substance use in its early phase.
Keywords: Alcohol, drug, psychotropic drugs, rehabilitation centres, sensation, substance use
|How to cite this article:|
Kumar G, Jnaneswar A, Rai S, Vinay S, Jha K, Singh A. Substance use and oral health sensations among substance users residing in rehabilitation centres in an Indian City. Indian J Dent Res 2022;33:7-13
|How to cite this URL:|
Kumar G, Jnaneswar A, Rai S, Vinay S, Jha K, Singh A. Substance use and oral health sensations among substance users residing in rehabilitation centres in an Indian City. Indian J Dent Res [serial online] 2022 [cited 2022 Sep 29];33:7-13. Available from: https://www.ijdr.in/text.asp?2022/33/1/7/353531
| Introduction|| |
In medicine, the term drug refers to any substance with the potential to prevent or cure disease or enhance physical or mental welfare, and in pharmacology to any chemical agent that alters the biochemical physiological processes of tissues or organisms. However, the term substance is more commonly used for psychoactive/psychotropic drugs which might be illicit or licit, even though the term is used more specifically for illicit drugs.
According to the national survey on the extent and pattern of substance use in India (National drug use survey) in the year 2019, alcohol is the most commonly used psychoactive substance. About 14.6% of the population (between 10 and 75 years of age) uses alcohol. Cannabis and opioids are the next commonly used substances in India. Odisha exhibits a rising trend in the number of drug addicts. The National Integrated Biological and Behavioural Surveillance (IBBS) 2014–2015 had revealed that children as young as 14 years of age start their first drug use in Odisha.
The adverse effects of substance use can be divided into three parts, which include the direct physical harm, the tendency of the drug to induce dependence and the effect of abuse on families, communities and society. The direct physical harm caused by substance use can be for short term and long term, depending on various drug- and host-related factors. Short-term effects on the general health can range from changes in appetite, wakefulness, heart rate, blood pressure and/or mood hypersensitivity to touch, sight, sound, clouded thinking, agitation, sweating, hyperthermia, tremors, vertigo, anxiety, irritability, abdominal pain, nausea, heart attack, stroke, psychosis, overdose and even death. Longer-term effects on general health include heart or lung disease, cancer, mental illness, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hepatitis, addiction and others. The short-term and long-term effects of substance use on general health are well known, including the effects of substance use on the oral cavity, such as transient chorea, buccolingual dyskinesia, perforation of the nasal septum/palate, bruxism, gingival recession, cervical tooth loss, xerostomia, acidic erosion of enamel, hyperkeratosis, dental caries, temporomandibular disorders and so on.
However, there is very minimal documentation of the oral health sensations as perceived by different substance users. According to Patrick Haggard (2014), oral somatosensory awareness refers to the somatic sensations arising within the mouth and to the information these sensations provide about the state and structure of the mouth itself and objects in the mouth. These sensations contribute to the short-term oral effects experienced by substance users.
From a public health perspective, substance use has long been a source of major concern, both for the individual's health and for the society as a whole. Moreover, there is scanty data on substance use in Bhubaneswar at present. Knowledge and clear understanding of these oral sensations might help oral health practitioners detect and report cases of substance use in its early phase, apart from only providing curative treatment. Thus, we conducted this study with the aim to test and determine the association between substance use and oral health sensations (short-term oral health effects). Our objectives also included determination of the association between socio-demographic profile of substance users and their pattern of substance use. Ascertaining the time of onset of oral sensations (short-term oral health effects) after the start of substance use and describing the self-reported oral health perception and practices of substance users were our secondary objectives.
| Materials and Methods|| |
A cross-sectional, questionnaire-based study was conducted on the inmates of deaddiction cum rehabilitation centres in Bhubaneswar city, Odisha, as identifying substance users in the general population was difficult, with cooperation and compliance being other issues. A list of nine drug rehabilitation centres in Odisha was obtained from the Department of Social Security and Empowerment of Persons with Disabilities, out of which seven were private centres and two were government-aided centres. Eight centres out of a total of nine were covered as consent could not be obtained from the director of one of the private centres. Universal sampling technique was followed. A total sample of 300 inmates were residing in these centres. Data collection was carried out from September 2019 till October 2019.
All inhabitants of the deaddiction centres who volunteered and gave their consent were included in the study, while participants with mental health disability who were forbidden to participate in the study by their psychologists and their counsellors were excluded from the study.
The questionnaire was prepared based on a previous study. The components of the questionnaire included socio-demographic profile of substance users with socioeconomic status calculated using the Kuppuswamy socioeconomic scale 2019, questions on the pattern of substance use, self-reported oral health perceptions and practices recorded on a 5-point Likert scale and self-reported oral health sensations (short-term oral health effects) experienced after substance use. The questionnaire was checked for its face validity and content validity by former drug addicts and public health experts. The questionnaire was then translated into the local language by a language expert and then back translated to English by a different individual who had a good understanding of both the languages. After making the necessary revisions, the questionnaire was pilot tested on 10% of the study population and the respondents' review contributed as a measure of face validity and content validity. The item analysis was carried out to test for the internal consistency and reliability, and the Cronbach's alpha was found to be 0.76, which depicted acceptable reliability. Final revisions regarding the list of substances used by inmates were made in both English and Odia questionnaires following the pilot study. A total of 221 inmates were included in the main study following the exclusion criteria and after excluding those who participated in the pilot study.
The study subjects were assembled at each respective centre with the help of their counsellors. They were briefed about the nature and the purpose of the study, and after obtaining informed and written consent from the participants, questionnaires were administered to them in the language they were comfortable with. Questionnaires were filled by the participants themselves to ensure anonymity and also because of the sensitivity associated with their past history. One centre was covered each day. Time taken to complete a questionnaire varied from 10 min to a maximum of 15 min. Completed questionnaires were collected back by the chief investigator.
Ethical clearance was obtained from the Institutional Ethics Committee, KIMS, KIIT University. Letter reference number: KIMS/KIIT/IEC/604/2019.
The collected data was analysed using Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM SPSS statistics for Windows, version 21.0; IBM Corp., Armonk, NY, USA). As the variables were categorical, the results are presented as frequencies. Chi-square statistics were employed to analyse the variations in sensations caused by different drugs and to find the association between socio-demographic profile and type of substance used. The level of statistical significance was set at 0.05 with a confidence interval of 95%.
| Results|| |
All the inmates were males. The socio-demographic profile of the inmates has been depicted in [Table 1]. Majority of them were single (56.1%), followed by married (40.3%) and divorced (3.8%) inmates.
Around 60.63% (134) inmates were polysubstance users and 39.36% (87) were single substance users. Alcohol was found to be the most commonly used substance, followed by ganja used by 57% (193) inmates [Table 2].
About 37.6% (83) inmates reported having very good oral health before starting substance use, while only 15.4% (34) described it as very good at present. Most of the inmates, 59.3% (131), felt that dental health could affect general health. More than half of the inmates, 54.8% (121), never had problem due to teeth/gums/mouth in the past 3 months. Majority of the inmates, 79.6% (176), brushed their teeth once daily and 78.7% (174) had never visited a dentist in the past 12 months. Not experiencing any problem was the most common reason for no visit during the last 12 months by 52.0% (115) inmates. Ignorant attitude towards oral health (15.8%; 35), fear/anxiety, costly treatment and others were some of the other reasons [Table 3].
Dryness of mouth was found to be the most commonly experienced oral health sensation among substance users (51.1% inmates). The difference between dryness of mouth (P < 0.0001), taste change (P = 0.027), numbness in mouth (P = 0.002), feeling like chewing something (P = 0.024), loose tooth (P = 0.026) and stammering/speech problem (P = 0.016) experienced by single and polysubstance users was found to be highly significant [Table 4].
About 36.7% of the inmates reported that they experienced changes (sensations/short-term oral health effects) after using substance for more than 1 year [Figure 1].
|Figure 1: Time of onset of short-term oral health effects (sensations) after the start of substance use|
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The difference in the age of start of substance use and marital status among the various substance users was found to be statistically significant, while the difference in socioeconomic status among the various substance users was found to be statistically non-significant (P = 0.129) [Table 5].
|Table 5: Association between the profile of substance users and the pattern of substance use|
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| Discussion|| |
Maximum number of inmates in our study belonged to the age group 18–36 years, were in upper middle socioeconomic group, were single and all were males. The age of subjects in a similar study reported by McGrath and Chan was found to be between 15 years and 25 years. Adedigba et al. reported that majority of the subjects belonged to the age group 21–30; however, unlike the present study, majority of them were married, secondary education being the highest level of education, with the annual income of the majority being in the range Rs 11,000–20,000. This disparity in socioeconomic status between the present study and the latter might be due to the sample selected.
In the present study, alcohol was found to be the most widely abused drug and the use of polysubstance was more common. This is in agreement with the findings of Adedigba et al. However, McGrath et al. reported all the inmates to be polysubstance users and the most widely used substance to be methamphetamine (speed). Hossain et al. reported that the most commonly used category of substance was heroin, followed by ganja and methamphetamine (yaba).
The age of start of substance use was found to be less than or equal to 18 years for a majority of the inmates. The mean age of first substance use as reported by Day et al. was 20 years. Maruf et al. reported that more than three-fourths (76.1%) of respondents started to consume nicotine before the age of 20. For other substances, the majority of respondents (41.0%) started between the ages of 16 and 20.
Neira et al. reported the average duration of use as reported by patients was 15.0 ± 11.2 years, which is similar to our study finding.
Majority of the inmates consumed substance more than three times a day and it had been few months since they had last consumed drugs. The reason for this could be restrictions on substance use post-admission in rehabilitation centres.
The mode of substance intake preferred by the majority was oral route, followed by smoking. Maximum inmates used multiple routes to take substances owing to the fact that the majority were polysubstance users.
Neira et al. reported that the most frequent administration route was smoking, followed by inhalation. Maruf et al. mentioned that most respondents used more than one route of administration depending on the substance used.
Recreation, stress and family problems were a few reasons stated by the inmates for engaging in substance use. Most of the inmates reported more than one reason for their substance use. Maruf et al. mentioned curiosity, peer pressure and enjoyment or fun to be the common reasons for initiating substance use.
Majority of the inmates cleaned their teeth once daily and believed they had very good oral health before they started substance use, while this perception was not the same after drug use for majority of the inmates. Rooban et al. reported a similar finding where the maximum drug abusers brushed their teeth once daily. Hossain et al. reported that the drug addicts followed an incorrect frequency of teeth cleaning. In this study, the inmates believed that oral health was related to general health. Majority reported of not experiencing any oral health problem in the past 3 months and had not visited a dentist in the past 12 months. Among those who had been to a dentist,the most common problems among those who had been to a dentist were toothache, dirty teeth and broken tooth. Similarly, Robinson et al. reported that a number of participants said that they frequently ended up in hospital casualty departments because of accidents. The reason for not visiting a dentist for majority of the inmates was that they did not experience any problem. The obstacles in visiting a dentist as reported by Hossain et al. were ignorant attitude towards oral health (48%), fear of cost (32%) and bad monetary experience (25%).
The inmates reported that they experienced a wide range of oral health sensations/effects after taking substance. Dryness of mouth was the most commonly reported oral health sensation, followed by taste change, halitosis and dental sensitivity. Similar findings were reported by McGrath et al. and Adedigba et al., who found dryness of mouth as the most common sensation experienced. About one-third of the subjects noticed numbness in their mouth as reported by McGrath et al.; however, dissimilar finding was reported by Adedigba et al., the reason being small sample of opiate users in their study population.
The difference in the sensations experienced by single and polysubstance users was found to be significant for dryness of mouth, taste change, numbness in mouth, feeling like chewing something, loose teeth and having speech difficulty. There was a significant difference between single and polysubstance users who did not experience any sensation or short-term oral health effect.
About 36.7% of the inmates started experiencing changes in oral health after using substance for more than 1 year. Owing to the fact that few studies have recorded the duration of start of these short-term oral health effects, more research needs to be carried out in this direction. Ethical considerations do not permit conducting experimental research in this field, thereby limiting our boundaries by depending upon patient's perception. Solomons and Moipolai, in their clinical review, mentioned that some substance abusers experience pronounced effects in as little as 6 months to 1 year of starting to use the substance, whereas in a non-user, such manifestations would take several years (along with severe oral neglect) to develop.
There was a significant relationship between the age of inmates, socioeconomic status and various types of substances used, which implied that substance use has become a problem among teenagers and needs immediate attention. Polysubstance use was found to be more common among the upper middle class. The ease of availability of various substances is a matter of concern. Usage of multiple substances was found to be significantly high among singles and divorcees compared to married subjects. Alcohol was found to be commonly used by married inmates.
Strengths: Rehabilitation centre as a study setting had the advantage that all drug-addicted individuals were present at a single place. To reduce primacy bias, questions were positively as well as negatively coded. There were no proxy respondents as questionnaires were filled by all the inmates at the same time at each centre. As a self-administered questionnaire was used, the chances of interviewer bias were minimal.
Limitations: Social desirability bias would have been a major limitation in this study. Recall bias was also a limitation as the study was based on perceptions, ability to recall and judgement of the drug addicts. The state of mind of the inmates in the deaddiction phase would have greatly influenced their reporting. There are chances that the responses of those having premalignant lesions such as oral submucous fibrosis (OSMF) might have been affected by their lesions. Because majority of the subjects were polysubstance users, it was difficult to study the effect of individual substances in a 'cause and effect' scenario on the oral cavity.
| Conclusion|| |
Substance use disorders are a national concern. A wide range of oral health sensations (short-term oral health effects) are caused due to substance use, with dryness of mouth being the most common. These sensations can aid oral health professionals in detecting and reporting cases of substance use in its early phase. There also exists a link between the socio-demographic profile and pattern of substance use in Bhubaneswar. The government along with the oral health professionals need to combat this rising social maleficent through framing solutions, preparing policies and providing services to this section of our population.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Shilpa Rai
Department of Public Health Dentistry, Kalinga Institute of Dental Sciences (KIDS), KIIT University, Campus – 5, Patia, Bhubaneswar – 751 024, Odisha
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]