Table Of ContentShekarchizadehetal.BMCOralHealth2013,13:11
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RESEARCH ARTICLE Open Access
Oral health behavior of drug addicts in
withdrawal treatment
Hajar Shekarchizadeh1,2, Mohammad R Khami1,2*, Simin Z Mohebbi1,2 and Jorma I Virtanen3,4
Abstract
Background: Oral health behavior (OHB), one major factor contributing to proper oral health status, has been
addressed insufficiently in addiction literature. The aim of our study was to investigate OHB and itsdeterminants
among drug addicts inwithdrawal treatment.
Methods: Through a stratified cluster sampling method, we collected thedata from 685 patients in withdrawal
treatment inTehran using self-administered questionnaires on OHB components and conductinginterviews about
patients’characteristicsand addiction history. The T-test, ANOVA, and a linear regression model served for statistical
analysis.
Results: Ofthe patients, 48% reported brushing their teethless thanonce a day, more than90% used fluoride
toothpaste almost or always, and 81% flossed their teeth rarely or never. Eating sugary products twice a day or
more was reported by57% of the patients and 85% ofthem were current smokers. Poor OHB was associated with
malegender, lower education, being addicted mainly to crystalline heroin,starting drug abuse ata younger age,
and having a longer history of addiction (p<.05).
Conclusion: Poor OHB was found among the participants in drug withdrawal treatment. Preventive strategies on
oral health should be planned and be integrated into other health promotionprograms for addicts along with their
withdrawal treatmenttaking into account special groups athigher risk.
Keywords: Addiction, Substance abuse, Withdrawal treatment, Methadone maintenance,Oral health behavior
Background consumption, and poor oral hygiene, as well as smoking,
Drug abuse results in various individual and social seem to influence the oral health complications among
consequences and takes a heavy toll in terms of severe addicts[4].
health complications, risky behaviors, violence, and social Becauseoralhealthisanimportantpartofgeneralhealth,
problems [1]. In addition to the direct effects of drugs on healthandwellbeingarelikelytobeimprovedbyallefforts
oralhealth,drugabusemayaggravateoralproblemsindir- at oral health promotion. In oral health promotion activ-
ectlythroughitsadverseeffectsonuser’sbehaviorandlife ities, as well as in health promotion programs, the setting
style. Poor oral hygiene, a tendency toward consumption playsanimportantrole.Thishasledmanypeopleworking
of sweet foods, irregular eating patterns, poor nutrition, in this field to adopt a setting approach [5]. Rehabilitation
and irregular dental visits are prevalent among addicts settings such as addiction treatment centers help patients
[2,3]. In fact, for addicts, the effects of social and behav- feelsafeandhelpthemtakecontroloftheirlivesandfocus
ioral factors on their oral diseases are greater than is the moreontheirhealth[6,7].Thesesettingshencecanplayan
effect solely of drugs. Factors such as socio-demographic important role in changing patients’ behavior [8]. These
background, childhood access to dental care, sugar centers can also be considered as a great opportunity for
programs targeting oral health behavior (OHB) to become
integrated into other services provided for addicts.
*Correspondence:[email protected]
1CommunityOralHealthDepartment,SchoolofDentistry,TehranUniversity Improved access to dental health care via these settings
ofMedicalSciences,NorthKargarStreet,Tehran1439955991,Iran might lead to changing the patient’s behavior and life style
2DepartmentofOralPublicHealth,InstituteofDentistry,Universityof
and, in turn, to help improve the success of withdrawal
Helsinki,P.O.Box41,HelsinkiFI-00014,Finland
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Shekarchizadehetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Shekarchizadehetal.BMCOralHealth2013,13:11 Page2of7
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treatment [9]. In order to plan suitable and successful oral and the method of communication with the patients. A
health-promotion programs, the existing situation of detaileddescriptionofdatacollectionappearsinanearlier
patients’oralhealthbehaviorshavetobeassessed. report[12].
While OHB is one of the major contributing factors to
proper oral health status, not much is known about the Self-administeredquestionnaireandinterview
addicts’ behaviors. Few available reports from the UK In the clinics, after a brief explanation of the study, the
and USA highlight the poor OHB among these patients investigators asked the patients who volunteered to fill in
in terms of brushing habits, snacking, and recent visits the questionnaire on oral health. Completing the ques-
to a dentist [2,3,6]. Although Iran endures high rates of tionnaire took around 20 minutes. Participants were able
addiction to opiate drugs [10] and about 1.2 million to ask for explanations of the questions if necessary. The
addicts in need of treatment live in the country [11], no questionnairerequestedinformationonOHBcomponents
comprehensive published data exist on this group’s based on previously validated questionnaires [13,14]. The
OHB.Intotal, 700privateand150public centers,160of questionnaire and the feasibility of the method were
which are located in Tehran, offer outpatient services to pretestedinapilotstudypriortodatacollection.
patients[11]. To obtain patients’ addiction history and background
The aim of our study was to investigate the OHB of factors, the investigators conducted 10-minute structured
drug addicts in withdrawal treatment. In addition, we in-person interviews by use of a standard patient-
analyzed the associations between OHB and users’ characteristic form commonly serving as a framework in
characteristics and addiction history in order to identify addictionstudiesinIran[12].Basedonthemonthlyturn-
specialsubgroupsat greater risk. over of patients in each clinic, we continued data collec-
tionintheclinicstocoveralleligiblepatients.
Methods
Subjects Oral health behavior Oral self-care comprised questions
The present study was performed in addiction treatment about the frequency of tooth brushing, using fluoride
centers in Tehran, Iran. The target population comprised toothpaste, flossing, eating sugary products between the
drug users receiving methadone maintenance treatment main meals, and smoking. Dental attendance comprised a
(MMT) at these centers from January to May 2011. A questionastothetimeofthemostrecentvisittoadentist
multi-stage stratified cluster random sampling technique [13-16]. Each question had between 4 and 7 alternatives.
covered the three main socioeconomic areas of the city: ToobtainatotalscoreforOHBforeachpatient,basedon
north,center, and south.After dividingthe cityintothese the authors’ experience and the relevant literature [17-19],
three main strata, we selected clinics at random as appropriateweightswereassignedtoallcomponents,with
clusters. Since more than 95% of treatment centers were higher weights for health-promoting behaviors: frequency
private clinics, in order to achieve a homogenous group, of tooth brushing (0=less than once daily, 2=once daily,
weexcludedpubliccenters[12]. 4=twice daily or more), using fluoride toothpaste (0=
Considering the proportion of clinics in each of the rarelyornever,1=almostoralways),flossing(0=neveror
three strata, we randomly selected the clinics as clusters sometimes, 1=several times weekly, 2=at least once
in each stratum. In total, eight clinics (3 of 59 in the daily), eating sugary products between meals (0=twice
south, 3 of 64 in the center, and 2 of 27 in the north of dailyormore,2=oncedaily,4=notdailyorrarely),smok-
the city) entered the survey. To estimate sample size, ing (0=daily smoking, 1=current but not daily smoking,
proportional sampling was applied and sample size of at 2=nocurrentsmoking),andtimeofmostrecentvisittoa
least 320 persons was calculated. Because of the high dentist (0=never or more than 2 years ago, 1=between
number of edentates among addicts and to be able to one and two years ago, 2=during the previous year). We
compare various subgroups we extended data collection then summed up the scores for the components to calcu-
to cover the monthly turnover of MMT patients in the latethetotalOHBscorewitharangefrom0to15.
selected clinics. Of 813 participants (response rate: 72%),
128 (16%) were totally edentulous and were excluded Addiction history We asked the patients about their
from thestudy. main drug of abuse (the most problematic drug which
made the patient enter treatment), age when drug abuse
Datacollection began, duration of addiction, and duration of current
The data were collected with both self-administered treatment.
questionnaires and with conducting interviews. Three
trained senior dental students conducted the survey. Be- Background factors We asked the patients their gender
fore data collection, the investigators underwent training and age. In addition, their residential area, education,
about the content of the interview and the questionnaire, and marital and employment status served as indicators
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for socioeconomic status (SES). These variables were Table1Characteristicsofaddictsinwithdrawal
dichotomized as follows: for education, higher education treatment(n=682)
(diploma or higher)=1; lower education (less than dip- Variable Number Percentage
loma)=0; for marital status, married=1; single (single, Gender
widow, divorced)=0; for employment status, employed
Male 656 96
(full or part-time)=1; unemployed (unemployed, retired,
Female 29 4
homemaker, and student)=0; and for residential area,
Total 685a 100
affluent (north and center) = 1; non-affluent (south)=0.
These were combined by summing up the dichotomized Age
scores (range: 0to4). 18-24 30 4
25-34 268 39
Ethicalapproval
35-44 214 32
The Tehran University of Medical Sciences Ethics Com-
45-54 119 17
mittee approved the study. Participation in the study was
55≤ 51 8
voluntary, and all respondents provided their written
informed consent. To provide as much confidentiality as Total 682 100
possible, we used an anonymous patient-characteristic Educationstatus
formandananonymousquestionnairefordatacollection. 0-5 64 10
6-12 436 65
Statisticalanalysis
13≤ 168 25
The data was analyzed with the Statistical Package for
Total 668 100
the Social Science (SPSS for Windows, version 18.0/PC;
SPSS, Chicago, IL, USA). Student’s t-test and analysis of Employmentstatus
variance (ANOVA) served for statistical analysis (level of Full-timejob 385 57
significance<.05). A linear regression model was fitted Part-timejob 133 19
to the data to analyze the relationship between inde-
Unemployed 101 15
pendentvariablesandtotal OHBscore.
Others(student,retired,homemaker) 62 9
Total 681 100
Results
Among 685 dentate patients who completed the ques- Maindrugofabuse
tionnaire, 3 did not agree to be interviewed resulting to Opium 444 65
a sample size of 682 participants. The mean age of the Crystallineheroin 183 27
patients was 38.2 years (SD 10.1; range 20–79); 96%
Others 52 8
were men. Their background characteristics and addic-
Total 679 100
tion history are presented in Table 1. The main drugs of
Ageofstartingdrugabuse(years)
abuse were opium (65%) and crystalline heroin (27%),
and the age when drug abuse began was 18 to 24 years ≤17 103 15
foralmosthalf ofthepatients. 18-24 311 46
Table 2 presents the OHB of the drug users in with- 25-34 190 28
drawal treatment. Around half the patients (48%) 35≤ 73 11
reported brushing their teeth less than once daily. More
Total 677 100
than 90% used fluoride toothpaste almost or almost al-
Durationofaddiction(years)
ways. Aclear majority (81%) never or rarely flossed their
teeth. More than half the patients (57%) reported eating <1 21 3
sugary products twice daily or more often between their 1-5 210 31
main meals. Of the patients, 85% were current smokers, 6-10 205 31
among whom a great majority were daily smokers. Al- 11≤ 236 35
though more than half the patients (57%) had visited a
Total 672 100
dentist during the previous year, for 25% of the
Durationofcurrenttreatment(months)
participants the most recent visit was more than 2 years
previouslyornever. <1 79 12
The mean OHB score was 5.6 (SD 3; range 0–15) 1-5.9 193 28
among participants. Table 3 presents the mean OHB 6-11.9 149 22
scores according to patients’characteristics and addiction
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Table1Characteristicsofaddictsinwithdrawal The linear regression model (Table 4) confirmed the
treatment(n=682)(Continued) results of univariate analysis: having been addicted to
crystallineheroinasone’smaindrug,startingdrugabuse
12-23.9 124 18
at a younger age, and longer duration of addiction were
24≤ 133 20
associated with lower OHB scores (p<.05). In addition,
Total 678 100
female gender and higher SES were significantly
aRegardlessofinterview,participants’genderwasrecognizedbasedon associated withhigher OHB scores(p<.05).
theirappearance.
history.Inunivariateanalysis,ahigherOHBscorewassig- Discussion
nificantly associated with female gender, older age, and One of the prevalent problems among drug users is oral
higher education (p<.05). Moreover, patients categorized health diseases requiring serious attention, since a mu-
as “other” regarding employment status (student, retired, tual relationship seems to exist between addiction and
homemaker), and those from clinics located in the center oral complications: addiction can cause oral diseases
regionhad higherOHBscores (p<.001).A significant as- [20-23], but then oral health problems may also lead to
sociation existed between OHB score and patients’addic- intake of illicit drugs for pain relief [24]. The topic of
tion history: crystalline heroin users had lower OHB oral health, however, has not been addressed sufficiently
scores(p=.007).Patientswhohadstartedusingdrugsata in addiction literature [25]. The present study of oral
younger age andthosewho hada longer historyofaddic- health behavior and its determinants reveals generally
tion showed significantly lower OHB scores (p<.001). poor OHB by these patients in withdrawal treatment.
Duration of current treatment was not associated with For crystalline heroin users especially, those who started
patients’OHB. drug abuse at younger ages and had been addicted
longerhadinadequate OHB.
Table2Oralhealthbehaviorprofileofaddictsin
withdrawaltreatment(n=685) Oralself-careprofileofaddicts
The present study revealed poor oral self-care among
Variable Alternatives Frequency(%)
addicts receiving MMT, most of them not meeting the
Toothbrushing Noteveryday 324(48)
criteria for the recommended level of oral self-care
Oncedaily 266(39)
components: tooth brushing at least twice daily, applica-
Twicedailyormore 85(13) tion of fluoride toothpaste always or almost always, and
Total 675 snacking on sugary products between meals less than
Useoffluoridetoothpaste Rarelyornever 47(7) once daily [15]. As only about 14% of the patients
brushed at least twice daily and flossed on a daily basis,
Almostoralways 625(93)
73% snacked on sugary products once daily or more
Total 672
often and 85% were current smokers. In a study of adult
Dentalflossing Neverorsometimes 551(81)
methamphetamine users in Iowa, 6% of the patients
Severaltimesaweek 33(5) reported brushing twice daily or more often, and 17%
Oncedailyormore 93(14) used dental floss daily [2]; these findings are comparable
Total 677 to ours. In-treatment drug users in Delhi have reported
similar findings on frequency of cleaning the teeth (4%)
Consumingsugarysnacks Twicedailyormore 385(57)
[26]. In addition, Brazilian addicts undergoing rehabilita-
Oncedaily 111(16)
tion showed a similar habit of eating between meals as
Noteverydayorrarely 182(27)
in our study; however, dental flossing was reported by as
Total 678 many as 30% of those patients [27]. Another study in-
Smoking Dailysmoking 521(78) volvingItalianalcohol-addicted patientsinresidentialre-
Currentbutnotdaily 45(7) habilitation clinics showed that the frequency of twice
smoking daily or more frequent brushing was 54% [8], a much
Nocurrentsmoking 105(15) higher figure than we found. This emphasizes an urgent
Total 671 need to develop efficient oral self-care instructions for
suchvulnerableindividuals.
Timeofmostrecentvisitto Morethan2yearsago 158(25)
adentist ornever The literatureon OHB of addicts is scarce. However, in
a comparable special-needs patient group of hospitalized
1-2yearsago 115(18)
Danish psychiatric patients, tooth brushing at least twice
Previousyear 362(57)
dailywaspracticedby55%ofthepatients[28].Inanother
Total 635
study regarding oral self-care among diabetic patients in
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Table3Oralhealthbehavior(OHB)scoresofaddicts Table3Oralhealthbehavior(OHB)scoresofaddicts
accordingtotheirbackgroundsandaddictionhistory accordingtotheirbackgroundsandaddictionhistory
(n=682) (n=682)(Continued)
Variable OHBscore p-value <1 5.8(2.9) .563**
(Mean,SD)
1-5.9 5.5(2.9)
Gender
6-11.9 5.4(3.0)
Male 5.6(2.9) .020*
12-23.9 6.0(3.2)
Female 7.0(3.3)
24≤ 5.7(2.8)
Age
*t-test,**ANOVA.
18-24 5.3(2.4) <.001**
25-34 5.5(2.8)
Sweden, tooth brushing at least once a day was reported
35-44 5.4(3.1) by91%andproximalcleaningby52%ofthepatients[19].
45-54 5.6(2.8) InIran, a studyofOHB amonga groupof diabetic adults
55≤ 7.8(3.2) reported higher levels of recommended OHB than in our
study: brushing (28%), and flossing (47%) [29]. These
Education
comparisons point out the overall poor OHB among
0-5 4.3(2.9) <.001**
addicts and call attention to the serious need for improv-
6-12 5.4(2.7)
ing their behavior via preventive oral health care
13≤ 6.9(3.1) instructions.Giventhefactthatrehabilitationsettingsplay
Maritalstatus an important role in behavioral change [8], oral health
Married 5.7(3.0) .050** promotion programs should be integrated into other
servicesprovidedforaddictsintreatmentcentersinorder
Single 5.8(3.0)
toachievestabletreatmentoutcomes.
Others 4.7(2.6)
Employmentstatus
Dentalattendanceofaddicts
Full-timejob 5.6(3.0) <.001** Regarding use of dental services, around half the
Part-timejob 5.3(2.8) participants in our study (43%) had not visited a dentist
Unemployed 5.1(2.8) during the previous year. Similar findings have emerged
among drug users in the USA, with around 52% of drug
Others(student,retired,homemaker) 7.5(2.8)
users having their most recent dental visit more than
Areaofresidence
one year ago [30], and in the UK, with addicts (54%) less
North 5.6(3.1) <.001**
likely to visit a dentist during the previous year than
Center 6.4(2.9) were non-drug users (84%) [3]. Dental attendance at an
South 5.0(2.8) even lower rate occurs among alcohol-addicted patients
Maindrugofabuse in Italy (37%) [8], and for example in psychiatric patients
inDenmark(31%) [28].
Opium 5.8(3.0) .007**
Dental attendance among MMT patients in our study
Crystallineheroin 5.0(2.6)
was comparable to that of the general adult population in
Otherdrugs 6.3(3.4)
Tehran (52%) [31] and also to that of Iranian diabetic
Ageofstartingdrugabuse patients (47%) [29]. This implies that unlike in the UK [3],
≤17 4.9(2.6) <.001** underlyingfactorsassociatedwithdentalattendanceinIran
18-24 5.5(2.8) may be rather similar among various groups. However,
such factors as problems in registering with a dentist, hav-
25-34 5.7(3.1)
ing been refused access to treatment, stigmatization, and
35≤ 7.2(3.3)
negativeattitudesofhealthprofessionalstowarddrugusers,
Durationofaddiction(year) users’anxietyand fear of dentists,low importance to them
<1 7.9(2.8) <.001** of personal appearance, and poor socioeconomic status
1-5 6.4(3.0) maybeassociatedwithdentalvisitsamongdrugusers[3].
6-10 5.2(2.9)
11≤ 5.1(2.8) FactorsassociatedwithOHBofaddictsinwithdrawal
treatment
Durationofcurrenttreatment(month)
OHB among addicts was clearly associated with back-
ground and socioeconomic status. Poor OHB was not
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Table4Factorsassociatedwithoralhealthbehaviorscoresofaddictsbyalinearregressionmodel
Model Unstandardizedcoefficients Standardizedcoefficients p-value 95%ConfidenceintervalforB
B Standarderror Beta Lowerbound Upperbound
Gendera 2.15 0.62 0.14 .001 0.93 3.37
Socioeconomicstatusb 0.43 0.12 0.14 <.001 0.19 0.66
Maindrugofabusec 0.60 0.27 0.09 .027 0.07 1.14
Ageofstartingdrugabuse 0.07 0.02 0.17 <.001 0.04 0.10
Durationofaddiction −0.05 0.02 −0.11 .008 −0.08 −0.01
amale=0,female=1.
bSumvariableofthefollowingvariables:education,(diplomaorhigher=1;lessthandiploma=0);maritalstatus,(married=1;single=0);employmentstatus,
(employed=1;unemployed=0);andresidentialarea,(affluent=1;non-affluent=0).
ccrystallineheroin=0,otherdrugs=1.
R2=0.11.
equally distributed among the MMT patients: male meaning that we cannot generalize these findings to
participants and those less well educated were at greater all drug users [12]. Our subjective data collection (self-
risk. This is in line with other studies of OHB in general reported data) may be another limitation of the study.
populations and among certain groups [18,28,32-34]. We tried to overcome the possibility of over-reporting
However, since the gender distribution in the study was of desirable behaviors by using an anonymous self-
skewed, this result should be interpreted with caution. administered questionnaire to obtain an accurate picture
The lowest score of OHB was among unemployed ofthesituation.
participants, with a higher level of OHB for students,
retired people, and homemakers, which might be due to Conclusion
the latter two groups’ having more free time, and be-
Our study demonstrates poor oral health behavior
cause of the importance of good appearance among the
among addicts in withdrawal treatment, and especially
students [35]. Participants from clinics located in the
those less educated and those addicted to crystalline
central region reported better OHB, whereas the lowest
heroin as being at greatest risk for oral diseases. Educa-
OHB score existed among patients from the southern
tional and preventive strategies on oral health should be
region which reportedly had the lowest level of SES, in
integrated into other care provided for addicts, taking
linewith findingsfor Slovenia [18].
into account distinctpatient subgroups.
It is noteworthy that inadequate OHB appeared espe-
cially among crystalline heroin users, those who reported Abbreviations
startingdrugabuseatayoungerage,andoneswithlonger OHB:OralHealthBehavior;MMT:MethadoneMaintenanceTreatment;
SES:SocioeconomicStatus.
history of drug abuse. Thus, it seems that not only addic-
tionbutalsothekindofdrugusedandthecharacteristics
Competinginterests
of drug abuse may play an important role in OHB [22].
Theauthorsdeclarethattheyhavenocompetinginterest.
These findings may have implications for oral health pro-
motion among addicts through targeting of specific Authors’contributions
subgroups. General practitioners and specialists in sub- Allauthorswereinvolvedintheconceptionanddesignofthestudy.H.S.
carriedoutdatacollection;H.S.andJ.V.performedstatisticalanalysesand
stance abuse should advocate oral health care and inte-
interpretationofthedata.Allauthorsparticipatedineitherdraftingorcritical
grate it into other general care in treatment settings and revisingthemanuscript.TheFinaldraftofthemanuscriptwasapprovedby
educationalprograms. allauthors.
Acknowledgements
Strengthsandlimitationsofthestudy
ThisstudyhasbeensupportedbyTehranUniversityofMedicalSciencesand
The stratified cluster random sampling method and the HealthServicesGrantnumber12900.
large sample size of 813 with a high response rate of
Authordetails
72% provided a good overview of the patients in treat-
1CommunityOralHealthDepartment,SchoolofDentistry,TehranUniversity
ment. The study focuses on the extent and distribution ofMedicalSciences,NorthKargarStreet,Tehran1439955991,Iran.
of oral health-related behaviors of drug addicts in with- 2DepartmentofOralPublicHealth,InstituteofDentistry,Universityof
Helsinki,P.O.Box41,HelsinkiFI-00014,Finland.3DepartmentofCommunity
drawal treatment in Tehran and thus casts light on a
Dentistry,UniversityofOulu,P.O.Box5281,OuluFI-90014,Finland.
fieldnot researched indevelopingcountries.Thepresent 4DepartmentofPublicHealth,UniversityofHelsinki,P.O.Box41,Helsinki
study was cross-sectional in nature. Since this popula- FI-00014,Finland.
tion is not readily accessible, a representative sample of
Received:20September2012Accepted:28January2013
the whole population of addicts is difficult to achieve, Published:31January2013
Shekarchizadehetal.BMCOralHealth2013,13:11 Page7of7
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