Year : 2008 | Volume
: 12 | Issue : 1 | Page : 16--21
Dental and oral health status in drug abusers in Chennai, India: A cross-sectional study
T Rooban1, Anita Rao2, Elizabeth Joshua1, K Ranganathan1,
1 Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai, India
2 Director, Medical Services, TTK Hospital, TT Ranganathan Clinical Research Foundation, Chennai, India
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, 2/102 East Coast Road, Uthandi, Chennai - 600 119
Aim: To ascertain the oral health status and dental health status of drug abusers (DA) and compare them with those of non-drug-abusing dental patients.
Design: Hospital-based cross-sectional study.
Setting and Participants: Hundred consecutive male DA attending rehabilitation center for drug abuse and age-matched 100 non-drug abusers attending the outpatient department of a dental college hospital.
Measurements: Detailed history and clinical findings were recorded in a predetermined format by trained physician and dental surgeons. Data entry and statistical analysis were done using SPSS 10.0.5®
Variables: Oral mucosal lesions (OML), dental lesions (DL), «SQ»decay, missing, filling teeth«SQ» index (DMFT), brushing material (toothpaste/others), mode (toothbrush/others), and frequency per day (once/twice).
Results: The occurrence of at least one oral mucosal lesion was 49% in drug abusers and 6% in controls, the difference being statistically significant ( P = 0.00). In brushing habits, DL were significantly associated with brushing material ( P = 0.005) and frequency ( P = 0.001) when a comparison was made between DA and controls. The difference of ≤7 in the DMFT score between DA and controls in relation to material used for brushing ( P = 0.04) and frequency of brushing ( P = 0.001) was statistically significant. For any oral mucosal lesion, odds ratio (OR) was 15.1 (95% CI, 6-37.5); for any potentially malignant states, OR was 54.4 (95% CI, 3.2-911.3); for dental caries, the OR was 3.3 (95% CI, 1.8-5.9); and the OR for extrinsic stains was 8 (95% CI, 2.7-24).
Conclusion: A large gap exists with respect to dental and oral health status between DA and the general population. DA are at 54.4 times higher risk for having a potentially malignant state. These factors highlight the need for regular oral examination and dental treatment in DA.
|How to cite this article:|
Rooban T, Rao A, Joshua E, Ranganathan K. Dental and oral health status in drug abusers in Chennai, India: A cross-sectional study.J Oral Maxillofac Pathol 2008;12:16-21
|How to cite this URL:|
Rooban T, Rao A, Joshua E, Ranganathan K. Dental and oral health status in drug abusers in Chennai, India: A cross-sectional study. J Oral Maxillofac Pathol [serial online] 2008 [cited 2023 Mar 27 ];12:16-21
Available from: https://www.jomfp.in/text.asp?2008/12/1/16/42191
'Substance abuse' is a disorder characterized by repetitive drug use that results in social or economic distress and is often associated with medical problems. 'Drug addiction' is a chronic, relapsing disorder characterized by compulsion to take a drug and loss of self-control in limiting drug intake.  The substances or drugs may be natural or synthetic, the use of which has a psychoactive effect and alters or modifies the functions of a living organism. Globally, the number of drug abusers in 2007 was 200 million, i.e., 4.8% of the global population.  In the latest reports with regards to Indian context, 11.35 million persons were addicted to drugs. 
Drugs commonly abused are narcotics (including poppy, opium, morphine, codeine, heroin, brown sugar, opioids, meperidine, pethidine, and methadone), cannabis (marijuana, hashish, and dried parts of cannabis plant), stimulants (amphetamines, cocaine), hallucinogens (LSD, phencyclidine, mescaline, and psilocybin), depressants (barbiturates and benzodiazepines), and miscellaneous (antihistaminics, solvents in aerosols, glue, and whitening fluid).  In India, the abuse of alcohol, cannabis, and raw opium has been traditionally known; while the abuse of synthetic narcotic drugs and psychotropic substances is comparatively a new phenomenon. 
Medical complications of drug addiction are relevant to dentistry and include abscesses at site of injection, viral hepatitis, human immunodeficiency virus (HIV) infection, endocarditis and anesthesia-related complications. Studies have shown that the dental health and oral health are affected by drug abuse. ,,,, Concomitant use of other psychotropic substances such as tobacco, alcohol and areca nut further deteriorates the health status of the individual. Drugs abused adversely affect the oral soft and hard tissues (dental caries, periodontitis) or may lead to potentially malignant states (leukoplakia, oral submucous fibrosis) or may predispose to oral infections (candidiasis, gingivitis) by compromising local immunity. 
Description of the oral and dental lesions among drug abusers (DA) in south India is sparse.  Given this paucity of information, a hospital-based cross-sectional study was performed to ascertain the prevalence of oral health status and dental health status among DA and compare them with those of non-drug-abusing dental population in Chennai, South India.
Materials and Methods
The study group constituted 100 consecutive male DA examined over a period of 13 months (September 2003 to October 2004) and attending Ragas Dental College and Hospital, Chennai, referred from TTK Hospital, Chennai, India. TTK Hospital is a nongovernmental organization (NGO) run by T. T. Ranganathan Clinical Research Foundation, Chennai and involved in the rehabilitation of alcohol and substance abusers. This hospital serves the local district population and those from adjoining districts and states, including Karnataka, Andhra Pradesh and Kerala and is recognized by the Regional Office of South Asia, United Nation's Office of Drug and Crime, as a training institute for NGOs involved in the prevention and treatment of alcohol and drug abuse. Ragas Dental College and Hospital, Chennai, caters to the oral hygiene and dental treatment needs of the patients enrolled at the center.
All DA in the study were using drugs at least twice in a week and were having features of tolerance, withdrawal symptoms and continued use despite social, economic and medical problems. Occasional users were not included in the study.
The controls were chosen from the outpatient department of Ragas Dental College and Hospital, Chennai, Tamil Nadu. A random selection method was used, in which every tenth male patient of the outpatient department who had no habit of drug abuse was included in the study. One control was then selected from among them for each of the drug abusers, matched by exact age. Consent was obtained from all DA and controls and a comprehensive clinical history was taken and recorded by dental surgeons and trained physician in a predetermined format.
Complete history, including various habits [brushing (material - tooth paste/others; mode - toothbrush/others; frequency - once/twice), alcohol, chewing (tobacco and/or areca nut) and smoking], was recorded. The period of interview and examination lasted for 30 minutes. No hematological or biochemical tests were performed during the examination. Lesions were diagnosed as per the clinical features  and divided into OML (include all oral mucosal soft tissue lesions) and DL (include dental hard and soft tissue lesions).
The study population was broadly divided into two groups: the DA (drug users) and controls (non-drug users). Based on smoking, alcohol (beer/wine/spirits) and chewing (areca nut and/or tobacco) habits, the study population was categorized without any overlap into no habitual substance abusers; only tobacco smokers; only alcohol users; those who chewed areca nut with/without tobacco; tobacco smokers who used alcohol; tobacco smokers who chewed areca nut with/without tobacco; alcohol users who chewed areca nut with/without tobacco; and tobacco smokers who chewed areca nut with/without tobacco and used alcohol. According to age, the study population was stratified into 5 groups as those aged ≤25 years, 26 to 30 years, 31 to 35 years, 36 to 40 years and >40 years.
The frequency of OML and DL was noted down. DMFT (decay, missing, filling teeth) index was employed to assess the prevalence of caries.  DMFT index is a system that is a measure of number of teeth affected with dental caries or missing or filled due to dental caries. The third molars were not included in the DMFT scoring. DMFT score was categorized into ≤7 (25% of 28, the maximum possible DMFT score) and >7 for comparison.
Data were entered and analyzed using Statistical package for Social Services® , version 10.0.5. Descriptive statistics were presented for all the variables. Pearson's chi-square test was done to find the association of drug abusers and controls with religion, education, occupation, marital status, brushing habits, other habits, OML, DL and DMFT. Odds ratio (OR), 95% confidence interval (CI), was presented for significant variables for any oral and dental lesion and habits. P value of ≤0.05 was considered statistically significant.
[Table 1] gives the study subjects' details regarding education, occupation, brushing habits, medical problems, OML, DL and DMFT distribution. Education, occupation and marital status had a statistically significant difference between the drug abusers and controls ( P = 0.013, 0.00, 0.00 respectively). Fifty percent of DA and 34% of controls had attended college (either higher secondary/junior college/diploma/graduate/postgraduate courses) and 30% of DA and 52% of controls had attended secondary school (classes between 6 th and 10 th grade) ( P = 0.013). Twenty percent of DA did business, 14% were unemployed, while 13% were unskilled persons and 9% were students. In contrast, 45% of controls were unskilled persons, 9% were unemployed and 3% were students ( P = 0.000). Fifty-six percent of DA and 78% of controls were married ( P = 0.000).
Nineteen percent of the study population belonged to ≤25 years age group; 17% were in 26 to 30 years; 26%, in 31 to 35 years; 28%, in 36 to 40 years; and 13%, in >41 years age group. The age range was 18 to 48 years, with a mean of 32.78 years. The mean age of initiation into drug abuse was 24.88 years, varying from 12 to 41 years of age.
With regards to brushing habit, 89% of DA and 99% of controls used toothpaste ( P = 0.003), 94% of DA and 99% of controls used toothbrush ( P = 0.05) and 83% of DA and 97% of controls brushed once daily ( P = 0.001).
Among the substances abused, 19% of DA and 21% of controls smoked tobacco only; 44% of DA and 5% of controls smoked tobacco and used alcohol; 19% of DA smoked tobacco, chewed areca nut with/without tobacco and used alcohol; 2% of DA and 65% of controls did not use any other psychoactive substances. There was a statistically significant difference between DA and controls with regards to habit ( P = 0.000).
Of all the DA, 87% smoked tobacco, 71% used alcohol and 34% chewed areca nut with or without tobacco. Of the controls, 27% smoked tobacco, 8% used alcohol and 6% chewed tobacco with or without areca nut. The difference was statistically significant ( P = 0.000).
Among DA, 51% were single drug users and 49% used more than one drug. Of them, 90% used narcotics [morphine (1%), codeine (1%), heroin (4%), brown sugar (61%), bupenorphine (19%), pentazocine (4%)], 41% used cannabis [marijuana (3%), dried parts (38%)], 22% used central nervous system depressants [benzodiazepine (22%)], 1% used central nervous system stimulants (cocaine 1%) and 22% used miscellaneous substances [antihistaminics (21%) and whitening fluid (1%)]. With regards to mode of abuse, 16% ingested drugs, 42% inhaled or smoked or snorted drugs, 6% preferred intravenous (IV) method, 5% either inhaled or ingested drugs, 3% either ingested or used IV method, 20% inhaled or smoked or used IV method and 8% used all methods.
Forty-nine percent of DA and 6% of controls had at least one oral mucosal lesion ( P = 0.000), and 91% of DA and 95% of controls had at least one dental lesion. The mean DMFT for drug abusers and controls was 4.84 and 3.73 respectively, this difference being statistically significant ( P = 0.000). A DMFT score of ≤7 was observed in 79 DA and all controls, the difference being statistically significant ( P = 0.000). Among DA, of all teeth examined, it was observed that the mean number of decayed teeth was 2.9; missing teeth, 1.62; and filled teeth, 0.32; while in controls, it was 3.03, 1.71 and 1.67 respectively. Of all the teeth examined in DA, 10.36% were decayed; 5.79%, missing; and 1.14%, filled; while in controls, 9.85% were decayed, 2.75%, missing; and 0.71%, filled. The difference was statistically significant ( P = 0.000).
[Figure 1] compares the age of occurrence of OML and DL. The common age of occurrence of OML and DL in the study population was 31 to 40 years.
[Table 2] compares the brushing habits of DA and controls in relation to DL, OML and DMFT. Material used for brushing and frequency of brushing differed significantly between DA and controls with regard to causation of DL ( P = 0.005; P = 0.001 respectively). The difference of ≤7 in the DMFT score between DA and controls in relation to material used for brushing ( P = 0.04) and frequency of brushing ( P = 0.001) was statistically significant.
The occurrences of DL and OML among study population with varying habits were compared. Smoking and alcohol use increased the risk of DA for having DL and OML (OR of 17.38 and 12.25 respectively) as compared to controls. DA were at a risk of 33.69 and 39.25 for having DL and OML when they used alcohol and indulged in smoking and chewing areca nut as compared to controls [Table 3].
The predominant OML in drug abusers were leukoplakia, smoker's melanosis, oral melanosis and nicotina palate, while in controls, the predominant oral mucosal lesion was smoker's melanosis. The common DL in drug abusers and controls were gingivitis, dental caries and periodontitis. As compared to controls, the DA had statistically significant odds for leukoplakia (OR = 42.13), smokers melanosis (OR = 3.21), oral melanosis (OR = 48.09), any oral mucosal lesion (OR = 15.05), any potentially malignant state (OR = 54.36), dental caries (OR = 3.25) and extrinsic stains (OR = 8) [Table 4].
Among 19% of DA, we observed melanotic lesions that appeared as a patch in lateral border of tongue that was bluish to black in color, which we referred to as oral melanosis. Care had been taken in such situations to rule out racial pigmentation and post-inflammatory melanosis. Of these 19 cases, 7 were single drug users (3 abused brown sugar, 3 abused dried parts of cannabis and 1 abused benzodiazepine) and the remaining 12 used more than one drug (Bupenorphine, 9; brown sugar, 9; dried parts of cannabis, 7; antihistaminics, 5; benzodiazepines, 3). Tobacco was used by all these 19 DA. Eighteen of them smoked tobacco and 1 chewed areca nut with tobacco.
The reported annual incidence rates (per 100 persons) among males in Delhi, India, for abuse of any substance, alcohol, tobacco, cannabis and opioids were 5.9, 4.2, 4.9, 0.02 and 0.04 respectively.  It was reported in 2004 that India had 8.75 million cannabis abusers, 2.04 million opiates abusers and 0.29 million hypnotics and sedatives abusers.  There are no reports of oral lesions in this high-risk population from south India. Given the significant number of DA in this part of the world, this study was performed to ascertain various OML, DL and DMFT scores in a selected hospital-based population in Chennai, South India and compare these with non-drug-abusing dental hospital-based population. To the best of our knowledge, this is the first report of oral lesions in DA in this part of the world.
Of the study population, 2% of DA and 65% of controls had no other psychoactive substance abuse, indicating that 98% of DA used other substances incidentally. Extensive use of these known carcinogens and co-carcinogens places them at a high risk of developing cancer.
The brushing habits significantly varied between the DA and controls. Occurrence of DL was not influenced by the abuse of drugs but was influenced by brushing habit, frequency and material used. Low DMFT score was associated with toothpaste use and frequency of brushing. Of all the examined teeth in DA, 5.79% teeth were missing and 1.14% were filled teeth as compared to 2.75% missing and 0.71% filled teeth in controls, which implies that the dental problems in DA were due to poor oral hygiene measures and this could be effectively influenced and corrected by proper education and counseling measures.
The present study shows a high predominance (49%) of OML in DA as compared to controls (6%), while DL had no significant difference between DA and controls. Interestingly, 21% of DA had potentially malignant states and this clearly shows that DA are a high-risk population for developing malignancy as compared to 1.3% in our earlier general dental hospital-based population.  Prevalence of leukoplakia and oral submucous fibrosis among DA in our study was 17% and 4% respectively; whereas in general dental patients in our dental hospital, it was 0.7% and 0.6%.  The high incidences of leukoplakia among DA with odds of 42.13 as compared to controls indicate that DA are highly vulnerable to this potentially malignant lesion.
We observed melanin pigmentation along the lateral border of tongue in 19% of the DA. This area of pigmentation appeared as diffuse pale bluish black macules of varying size, often extensive with ill-defined margins. Racial pigmentation, smoker's melanosis and post-inflammatory melanosis are possible differential diagnoses of this condition that need to be excluded. The cause of melanin pigmentation could be attributed to metabolic alterations, alteration in the hormonal levels, chronic malnutrition, anemia, or a change which chronic drug abuse produces when accompanied by tobacco smoking. It has been reported that in a study of 100 Greek DA, 35% had melanotic lesions in lip.  Smoker's melanosis was observed in buccal, labial, gingival and palatal mucosa of 17 DA (of 87 smokers) and 6 controls (of 27 smokers). Though this lesion is a physiological reaction to the tobacco smoke, an OR of 3.21 indicates that abusers are more vulnerable to this lesion more often than controls.
Oral hygiene was poor and incidence of dental caries was higher among DA than among controls. This was however related to their brushing habits and was not by drug abuse. This fact emphasizes the need for teaching and counseling DA to maintain their oral hygiene. The incidence of OML is higher among psychoactive substance abusers, as in earlier reported studies. 
The controls were drawn from a dental hospital-based population, hence the incidence of dental lesions is high among controls. The large difference between the upper and lower end of CI for OR in OML and DL among different psychoactive substance users and the individual OML and DL indicates that the data is not uniformly distributed. Further studies have to be done with larger sample size to estimate the associated risk for having OML among DA.
The prevalence of OML and potentially malignant states among drug abusers is high as compared to controls. Prevalence of DL when compared between drug abusers and hospital-based population was similar. The brushing material, frequency of brushing and mode of brushing were significantly different between the drug abusers and dental hospital-based controls. These factors highlight the need for regular oral examination and treatment of drug abusers, along with emphasizing the need for instituting proper oral hygiene maintenance, early detection and treatment of OML and specific potentially malignant states.
We acknowledge the support extended to us for this study by Dr. S. Ramachandran, Principal, Ragas Dental College and Hospital, Chennai; and Mrs. Jothi, Nursing Superintendent, T. T. Ranganathan Clinical Research Foundation, Chennai. We thank Mrs. R. Hemalatha, Biostatistician, Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai, for her valuable contribution in analyzing the data.
|1||Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrisons Principle of Internal Medicine. Alcoholism and drug dependency, Messing RO. 15 th ed. McGraw-Hill; 2003. p. 2557.|
|2||World Drug Report. United Nations Office on Drugs and Crime publication. Geneva: 2007. p. 30.|
|3||Ray R. Extent, Pattern and trends of drug abuse in India. Ministry of social justice and empowerment, Government of India and United Nations office on drugs and crime, Regional office of South Asia. New Delhi: Executive Summary; 2004. p. 7.|
|4||World Drug Report. United Nations Office on Drugs and Crime publication. Geneva: 1997. p. 34-8.|
|5||Porter S. Oral health sensations associated with illicit drug abuse. Br Dent J 2005;198:147.|
|6||Robinson PG, Acquah S, Gibson B. Drug users: Oral health-related attitudes and behaviors. Br Dent J 2005;198:219-24.|
|7||Charnock S, Owen S, Brookes V, Williams M. A community based programme to improve access to dental services for drug users. Br Dent J 2004;196:385-8.|
|8||Scheutz F. Dental health in a group of drug addicts attending an addiction-clinic. Community Dent Oral Epidemiol 1984;12:23-8.|
|9||Rees TD. Oral effects of drug abuse. Crit Rev Oral Biol Med 1992;3:163-84.|
|10||Thavarajah R, Rao A, Raman U, Rajasekaran TS, Joshua E, Hemalatha R, et al . Oral lesions of 500 habitual psychoactive substance users in Chennai, India. Arch Oral Biol 2006;51: 512-9.|
|11||World Health Organization. Oral Health survey: Basic Methods. Geneva; WHO; 1997.|
|12||Mohan D, Chopra A, Sethi H. Incidence estimates of substance use disorders in a study population from Delhi, India. Indian J Med Res 2002;115:128-35.|
|13||Siddiqui HY. National survey on extent, pattern and trends of drug abuse in India, Drug abuse monitoring system: A profile of treatment seekers, Ministry of social justice and empowerment, Government of India and United Nations office on drugs and crime, Regional office of South Asia. New Delhi: 2004. p. 3-9.|
|14||Saraswathi TR, Ranganathan K, Shanmugam S, Ramesh S, Narasimhan PD, Gunaseelan R. Prevalence of oral lesions in relation to habits: Cross sectional study in South India. Indian J Dent Res 2006;17:121-5.|