Dentistry Uncensored with Howard Farran

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Howard: It's just a huge honor for me today to be podcast interviewing Dr. Glenn R Hanson  DDS PhD. He received his DDS from UCLA in 73 and his PhD in pharmacology from the University of Utah and 78 and completed a fellowship at neuropharmacology in 1980 at the National Institutes of Health NIH Bethesda Maryland. He practiced dentistry full and part-time over a 10-year period. He is a tenured full professor of pharmacology and vice dean in the School of Dentistry he was the acting director of the National Institute of drug abuse at the National Institute of Health and recognized as a leading expert on the neurobiology of the psychostimulants stimulants as uppers. Dr. Hanson has given several hundred presentations around the world on his research and program development related to drug abuse and the public health implications. He has also testified multiple times before the United States Congress and the state of Utah legislature on issues of drug abuse policy and Medicaid dental strategies and is frequently interviewed by local and international press about this topics. He is a member of the state of Utah legislative Advisory Committee on drugs of abuse, he's the author of over 240 peer-reviewed scientific papers 13 editions of a textbook entitled drugs in society and has been awarded over 35 million dollars in NIH National Institute of Health grants to conduct research related to drug abuse and his treatment. Dr. Hanson has recently been involved in studying the effects of including comprehensive dental care as part of the treatment for substance use disorder and it was a really interesting article that caught my eye where was it, it was all over social media just this may 21st 2019 dental care helps drug abuse patients recover the studies showed the drug abuse patients who consulted dental professionals for major oral health problems stayed in treatment almost two times longer and then they quote yours truly this is a powerful synergy between oral healthcare and substance use disorder said Glenn Hanson, the study's first author and professor at the University of Utah. Dr. Hanson thank you so much for coming on this show today.

Gen: It's my pleasure

Howard: It's such a controversial subject it seems to be so emotional and I can tell by the words you use now you have a PhD like you call it you don't call it substance abuse you call it what do you call it substance...

Geln: Use disorder

Howard: Substance use disorder, so it seems like I just want to start this a little perspective it seems like when I got out of school in 87 the media said the doctors were the bad guy cuz there's grandma suffering from cancer she had surgery they won't give her any pain pills and we were the bad guys so we started giving them the pain pills and then the pendulum swung all the way to the other side now they're like well you naughty little boy look what you did to Grandma now she's a heroin addict and how do you how do you gauge between you need this opioid for pain but I don't want this to ruin your life and you become addicted to it?

Glen: Well I think it's one you have to train the provider the one who writes the prescription the one who assesses the risk on the part of the patient and to start off with they have to understand what substance use disorder really is most people know it is addiction but it's referred to now as SUD, SUD is defined in the dsm-5 manual and the dsm-5 manual these manuals are used for psychiatrists and mental health workers to diagnose mental health disorders and there's about 150, 200 pages of this manual that taught just about drug abuse and so in this last edition they decided not to refer to it as dependence or addiction but to call it substance use disorder so that's why you hear that new nomenclature in the last few years because this this switchin term that came out of the dsm-5 manual but that's what it's referring to basically is what most of us think of as far as addiction so providers need to know what the difference is between drug dependence, drug abuse and substance use disorder or addiction so forgive me if I use those two interchangeably because I I want to make sure that you're listening audience is aware of its addiction we're talking about the providers need to know that there's a difference between these three phenomena.

Howard: and the three were drug dependence, drug abuse and drug....

Glen: and substance use disorder or addiction

Howard: Interesting, now I've been hearing more and more that if you have a drug issue oh I'm not something I don't have the phd of this so I might just call them all drug issues but if you have a drug dependence drug abuse a substance use disorder that at least you know eighty percent of these people have an underlying mental diseased mental disorder do you agree with that or disagree with that?

Howard: I really disagree with it just because it is so distinct according to the individual all substance use disorder does not look the same it's kind of like a cancer you know sometimes we say oh yeah my friend has cancer well cancer isn't cancer isn't cancer isn't cancer because there's so many different forms and it works very differently in different people in substance use disorders the same way it's a very individual phenomena and so risk looks different environment looks different there are those who would claim that even those who have very low risk for substance use disorder if you put them in the right environment high stress, very very threatening where there's a lot of tension, a lot of demands placed on you and a very low self-image that you are still vulnerable to substance use disorder so it's the environment and it is also the risk the natural genetic risk and it may be the disease there are some diseases where like neurodegenerative diseases where there's damage done to the brain it could be done because of an accident a car accident, damaged a piece of your brain or it could be a pathology like a Parkinson's disease or Alzheimer's disease that makes you more susceptible to problems with drugs than when you were younger. So it's a time of life they could also have an impact as to whether you're suffering issues with SUD, so there is nobody that is immune under the right kind of circumstances to having these kinds of problems with these substances.

Howard: Humans are extremely complex aren't they?

Glen: They very much are.

Howard: I'm convinced at age 57 that I'm the only normal person on earth.

Glen: Well that sounds like a mental....

Howard: Have I just diagnosed myself?

Glen: I think so.

Howard: Dentistry is always in the news about opioids like this just recently opioids unnecessary for dental work doc says wrong American Dental Association recently reported dentistry is responsible for prescribing 12% of all instant release opioids Dr. Mojan Farjon DDS of Sutton advanced cosmetic dentistry talked to Fox News it's it's a tough call because well let's just talk wisdom teeth it seems like that's the procedure the news talks about the most little Billy came in he's 18, he got it's four wisdom teeth removed doctor routinely gave vicodin and now there's a problem so and then the ADA is even saying that the dentist prescribed twelve percent of instant released opioids is that too, well what were your thoughts about dentists and opioids?

Glen: I would say that the dental profession has sort of a unique niche in this big problem I testified I've been an expert witness I've been involved in committees both at the national and the local level discussing this issue who are the providers who are the individuals that we need to really focus our attention on in providing education so that they're involved in the solution and they're not involved in causing the problem and when dentistry comes up almost without exception for those who know I mean who really know what's going on here they see them as a piece of the puzzle usually they are used by individuals who have SUD as a means of filling a void of getting access to drugs for a short period of time so like over the weekend or whatever reason they've run out of their opioid or they don't have access to their supply maybe they're out of town and so they go to a dentist on a Friday afternoon when he or she is just about to close they say oh I've got this terrible root canal problem it hurts so bad is there any way you can give me a just a small prescription get me over the weekend I'll be here Monday. Well the dentist wants to go home doesn't know the patient accepts them but there were maybe they're dressed well they look like oh they shouldn't be having an SUD problem writes the prescription gives them 10 15 if he's really generous he gives him 20 so they get these they use them to carry them over until they can find the main source of their drug where they're getting hundreds tablets are not just getting 10 or 15. So they use the dental professionals as it means to hold them over until they can get access to the big numbers. Very rarely do you see dentists prescribing hundred of these opioids which are necessary in order to maintain an SUD person they're rarely the ones that are doing that they're there they're contributing but usually they don't start it and they also don't end it and they just kind of contribute in the middle kind of they're just sort of ignorant as to what's going on around them and they write their little prescription and and the SUD patient goes on his or her way.

Howard: When you say their source I hear other people this is, you know there's many many different opinions and angles on this but a lot of people say that when you look at the opioid deaths I mean and they're they're so high I mean they're incredibly high a lot of people say that that's a side effect of them being illegal that if they bought the opioid like say vicodin or hydrocodone at Walgreens it wouldn't have been cut with fentanyl and that when it's illegal and they drive to underground illegal manufacturing opioids the way they're made is a big part of the of the opioid death, do you think how do you wrap your mind around the pros and cons of it being illegal so this they buy illegal drugs cut with you know other things versus at least if they were illegal you would know a high quality laboratory made the opioid?

Glen: So there certainly is a fraction of individuals who overdose and die because there's some fentanyl or something else that they used to cut the medication these are going to be illegals your not gonna get these from the pharmacy you're not going to get them because of a prescription but you're going to get it because you went to the street for whatever reason and it may be that your prescriber usually a physician or PA your prescriber says enough is enough I'm really concerned you're getting too much so I'm going to come back, I'm not going to provide you with this stuff anymore and so they have to look elsewhere to satisfy the addiction and they go to the street and they take something that has fentanyl in it. So there are some deaths that come from this but they're the minority the majority of people who overdosed on opioids usually have multiple drugs in their system they have a prescription opioid in their system either an oxycodone maybe a morphine or they have a pyridine or it could be hydrocodone I mean there's a variety of drugs that they could be taken it could even be methadone it could be part of the treatment where they were using methadone to help them get off heroin and they're using it legally but they mixed it with other stuff so these folks and I've been an expert witness on a number of these locally and nationally and in every case that I worked on there are at least three other drugs in the system usually there was alcohol in it there was sixty percent of the time there's a benzodiazepine in it like a valium drug and then there is an over-the-counter or a common kind of drug in there either an antihistamine that they're using to try to get to sleep sometimes they have they have congestion and they're using the antihistamine or they have muscles that are jumpy and they're using a muscle relaxant like a soma so that's in there so there's three or four and then now we're seeing more and more as medical marijuana or recreational marijuana is becoming available they have THC in their system as well. So they've got three or four CNS depressants an opioid is one of them and they're working together and they typically die in their sleep so they also have natural physiological CNS depression because of the sleep they usually die about 2:00 or 3:00 in the morning somebody comes in the next morning it tries to wake them up and they can't wake them up because they have succumbed overnight. So it's not just opioids although opioids are a critical piece of the discussion it's other things that are happening in their life that they're trying to address other than just pain.

Howard: Yeah I mean there's been some very high profiles that everything you were saying remind me of the Whitney Houston case there's multiple things found in her bloodstream.

Glen: Typical

Howard: Yeah, do you think the legalization and another very controversial bar is the legalization of marijuana we're seeing that roll across the state do you think that will make some people leave the harder stuff like opioids and do something less toxic or less lethal like marijuana or what is your view of this wave of marijuana legalization?

Glen: Absolutely not I don't believe that for a second and I've worked in this field for 40 years now and I testified before the drug czar and before the administration when I was back at National Institute on Drug Abuse and at that time this was in 2001, 2002 we were very concerned about marijuana the drug czar had decided that they as their as their focused they were going to use campaign to try to discourage marijuana use and so they asked me to come and explain to the drug czar and their organization the DEA about marijuana and what does it look like and what are my concerns about the marijuana discussion and marijuana is a drug or as a group of drugs because marijuana is a plant, it's got a lot of stuff in it and it represents a category of drugs we call the cannabinoids so the active ingredient in marijuana is THC tetrahydrocannabinol a lot of us have heard about CBD which is cannabidiol but it's also kind of a cannabinoid that's related to THC. So there's a family of these drugs that are out there and people tend to think oh marijuana is what we're talking about we're really not and about marijuana we're talking about a category of drugs that have different properties but they have some similarities as well. So what does that mean in terms of the medical discussion is there a place for marijuana in treating disorders, I don't know if marijuana is the best example of what we want to use but there will be cannabinoid drugs that will give us selectivity and allow us to access body symptoms that will be useful and are being useful and treating disease. My big problem with marijuana one is the plant why do you want to use a plant that has all kinds of hundreds of chemicals that we don't nothing about as it means to introduce THC which is the drug you really after. I mean this doesn't even make medical sense and then to think you're gonna be able to control things such as dose control self administration when you've got a drug that is a very potent drug works with a lot of different systems it has a really bad profile in people who have mental health problems everybody accepts this if you take marijuana and you've got underlying problems such as psychosis or schizophrenia or bipolar disorder or affective disorder this drug can cause great harm to these people. Well fifty to sixty percent of the users it recreationally and prescription have underlying mental health disorders so we're giving the drug to the very people that it's most likely to create side-effects in. So it's just it's an it's a piece of stick of dynamite we've lit the fuse and now we're gonna sit back and see what happens with it as use patterns it exchange because people start using it more and more and more and more just like tobacco you know tobacco wasn't all that toxic when people only smoked once or twice a day when they got up to the two and three packs a day that we realized what a toxic substance this is. We'll see the same thing I have no doubt we'll see the same thing with marijuana as you start to get people who are smoking it as much as individuals smoke tobacco there were do the same kinds of stuff that'll damage the lungs it'll have problems it could cause cancers it'll have mental problems it'll alter neurological systems and then we're really really concerned about adolescent use we know there's good literature out there that says adolescents to use this while they're developing have a very high incidence of problems long term if not permanent problems but 90% of the first-time users of marijuana are adolescents it always has been that way even when it was illegal ninety percent of the of the first-time users are adolescents why do we think this will change if we make it legal or if we make it medical and adolescents say oh this can't hurt me this has been approved by physicians and the medical community this can only do me good and it's going to attract them to using this drug even more. I mean that's one thing we we've learned time and time again not just with marijuana but with every drug tobacco is the same way alcohol is the same way that adolescents are more interested in these drugs than adults are and so whatever you do in terms of making access easier for these compounds you better always ask the question what is this going to do to an already, already big problem with high adolescent use of these substances and are we ready to deal with this for the next 20 and 30 and 40 years while these folks grow up after bringing their brains up under the influence of marijuana.

Howard: but what do you think of a child's future when say from 12 to 22 they've been smoking marijuana daily?

Glen: Well one thing we already know and and these are hard studies to do because it's hard to get an IRB an institutional review board to approve giving an adolescent marijuana three times a day while they grow up I mean oh IRB's gonna do this so uh so all you can do is retrospective studies and go back and see if I can find somebody out there who self reports that they used it at a certain rate over the growth or during their developmental period. So it's retrospective and the self report but still we know we know that if they are exposed frequently they there will be a very high instance of addiction we know that it'll be very hard for them to get off of the marijuana just like tobacco when you use tobacco early on or alcohol you use them early on the brain changes its neural chemistry because it sees substances that are active and it'll alter the way those pathways form so now it's used to seeing it when they're it's adults they expect it almost as though it's a natural substance they expected and you try to come and take it away the brain does not like that because you've disrupted a homeostasis of the brain that had developed throughout its adolescent period and they'll have withdrawals there'll be really high cravings and motivation to use it, it'll be very hard to get them off of it.

Howard: Some people in dentistry or reporting that I'm the cannabis users need more anesthesia for surgery are you noticing that?

Glen: I could see why that could be the case here again were in an area that has not been well studied we think that the cannabinoid receptors these are the targets for things like THC or other substances related to the THC we know that some of them are involved in pain modulation and so if you are a user there's one thing we know about marijuana and that it causes tolerance and all the CNS depressants do this alcohol does it that benzodiazepines do it the opioids do it and marijuana does it they all cause tolerance so that the systems adjust if you use these drugs over and over and over again which means if you want to maintain the effect you have to increase the dose so as tolerance occurs you're dosing increases you either have to take the substance more often or you've got to find a more potent substance out there which is already happening with marijuana, the percent of active ingredients in marijuana is two to three times higher than we've ever seen it in the past so we're already cultivating higher more potent marijuana and some of this is because people are using it more and more and more they want the effect in order to do that you need a more potent substances like going from a hydrocodone to oxycodone to a fentanyl you know the hydrocodone doesn't work anymore it doesn't control anymore so you bump up to the next potency and then you go to the next potency. Well what do we do with marijuana what we do is we spoke more and we cultivate it so that the ingredient active ingredient is higher a higher percentage which also means it's more likely to cause side effects which is again what we're having the problem with our opioids because we're much more concerned about having fentanyl very high potency easy to kill people with fentanyl then we are with hydrocodone doesn't mean we're not concerned about hydrocodone because we certainly are but anytime fentanyl comes in to the discussion we all get really excited because we know it only takes micrograms to kill people with fentanyl it takes hundreds of milligrams to kill people with hydrocodone. Well we're seeing the same phenomena i'm not saying we've got a fentanyl cannabinoid out there although i'm also not saying but someday we may not find but we do see that we're getting higher potencies of the products. We don't have really good control over the cultivation of these products so coming back to your question about pain it is if you're using it a lot it's going to mess up with a lot of systems that have a cannabinoid element to them and to the extent that pain has a cannabinoid element you may be developing tolerance to that part of the pain pathway and so when you come and try to use traditional whether it's opioid or aspirin or acetaminophen or ibuprofen you find out you need more of it because it's developed a piece of its pain pathway has become tolerant it's not as sensitive as it once was because it's been seen that seeing the struggle over and over again so you gotta compensate by increasing the doses of these other drugs in order to control the path, that makes sense?

Howard: It does you're a very profound, there's a big history I wonder what you what lessons we've learned from history Samuel Johnson used to say the chains that have it are too weak to be felt until they are too strong to be broken and the opium wars in China I mean those were from 1839 to 1860 so it would be hard to say this is a new problem.

Glen: Oh it's not.

Howard: So it's not a new problem is it?

Glen: No it's not a new problem and yet we're not any smarter at addressing it we think we're fairly sophisticated all we know the pharmacology we know the molecular biology we know there's genetics we know this we know that we know the other and yet there are still people who are dying from overdoses there are still hundreds of thousands or millions of people who get addicted. The addiction is a little different I mean in those ancient days the Chinese days or the other societies that that could cultivate the the marjuana poppies are the opium poppies they eat for the most part we're either self administering or they had some herbal herbalist that would provide the raw material for them whereas today we have doctors and dentists and other prescribers who can give it to them and hopefully they're better trained at recognizing someone who's got a substantial risk potential and so they're careful and they manage and they watch closely and they warn their patients and they tell them how to avoid problems with it in a better way than they did anciently but I'm not sure we're all that much better in terms of outcomes it doesn't seem like or any better at preventing severe addiction or preventing overdoses and terrible tragedies with these substances.

Howard: What lessons do you think we should have learned from China I mean we're coming up on 2020, so 200 years ago China is one fifth of the world's population what do you think what do you think the main takeaway lesson is from the opium wars?

Glen: Well the history of the opium wars to the extent that I understand it is that that Britain who had lost a lot of its access to tea at tax revenue was looking for substitute and they came across opium from China I mean tea came from China so they had already engaged in in commercial transactions with China and they said well let's shift from tea let's go to another product and let's work on the opium the year producing it and you don't really want to produce it you're trying to control us so give it to us and we'll distribute it for you and make a lot of money on it and this went on for a while and and Britain did make a lot of money and then China said now we just can't do this anymore this is too destructive to our society we want to stop this and Britain said no no you can't but this is making a lot of money for our nation and so that's where they went to war Britain said no you have to give us and provide us this substance whether they had contracts or whatever and China said no we don't want to be the opium source for the rest of the world and they ended up fighting it and Britain gets Hong Kong and a bunch of other things but I think it illustrates where a society that is examining its problems carefully comes to the conclusion that enough is enough we have got to put a stop to this we can't let it take its natural course we have to intervene and try to restrict its access because it's going to hurt our society it already has it's gonna hurt it even more and they were willing to go to war in order to change that pathway around. I think we should look at them and say China figured it out they figured it how destructive it was to their society maybe we need to look at ourselves and see if we haven't been the providers of some of these opioid products through our pharmaceutical companies and maybe we need to step back and take a more responsive position as far as providing this stuff controlling it and making sure that people understand and the vulnerable are protected from it's addicting consequences.

Howard: There's a lot of high-profile trials over companies manufacturing the opioids Ron do you think those are well deserved or do you think people are what are your thoughts on those trials?

Glen: I would say yes and no I actually am fairly familiar with some of them just because of where he came from and my addiction background did my expertise and people have talked to me and asked for opinions and that sort of stuff I don't think that there are any innocence here but I don't think that there is a company that is so guilty that we want to totally drum it out of business and bankrupt it I'm it seems like everybody should take some responsibility, it's not just a company's fault the company's trying to make a product and and early on they were probably merchandising some of these products particularly the sustained-release ones with not fully understanding the potential of the addiction and the consequences from what I know and what I've seen once they started to realize what was going on they tried to correct and they tried to create forms and products that couldn't be abused in the same way the original ones by putting substances in the sustained-release products so that the addict wouldn't be tempted to solubilize it extract the oxycontin out and inject it so that I mean they were anxious to prevent addiction and I think they did things to try to prevent that addiction.

Howard: A lot of people are saying that there's no need for an opioid in dentistry that they often quote that if you alternate tylenol with aspirin every four hours that that was you know that that's even better than an opioid other people say well there's no clinical trials on that if someone said to you there's no need for opioids and dentistry period end of story implants wisdom teeth root canals well how would you answer that would you agree disagree?

Glen: I would say that if used properly the opioids it's a tool I mean all of these things are tools and all of them have side effects you know how many people we kill with aspirin every year because they bleed out or they have ulcers, perforated ulcers I mean aspirin when it's not used properly can be a very damaging toxic drug what about acetaminophen you know there are a lot of people who die from liver failure if they used to many acetaminophen and we had we didn't know this for a long time and now anybody that has underlying liver problems whether they have a hepatitis history or if they're an alcohol consumer they probably should not be using much acetaminophen because of the liver toxicity. So every one of these things has potential side effects so you got to do you need to do a benefit risk assessment one you need to look at the type of pain that's going to result is it inflammatory pain if it's inflammatory then a non-steroidal anti-inflammatory drug is probably the better drug, opioids can block that but they don't do anything for the inflammation so you may get two fours with the NSAIDs and eye inflammation as well as some analgesic. How severe is the pain going to be where is the pain coming from if it is a pain that's associated with the tea or with the bone or with the gingiva these are our tissues that respond fairly well to the NSDS if it's a pain that's coming from inside if it's coming from let's say the sinus or it's coming from internal structures they don't respond as well to NSDS and opioids would probably be a better option regardless of which are the ones you choose in terms of how severe is it the more severe I can get better analgesia with morphine than you'll ever get with ibuprofen acetaminophen aspirin or a combination thereof it's because opioids work at three different levels of the pain pathway the anti-inflammatories work at one maybe two and those are peripheral opioids tend to be more centrally more in the spinal cord and even up into the brain and the higher-level structures. So they do and they work at different places sometimes the best thing is to combine them I mean this is actually a nice synergistic combination if you if you get a hydrocodone and you combine it with acetaminophen or hydrocodone and you combine it with an aspirin you can get the best of both worlds and you don't have to use high doses of either one so that combination is is actually something that was taught a lot when I went to dental school and I taught in medical school and we taught the physicians the same thing and we teach our dental students now that same thing. So it's not like well throw those all the way because they're causing us problems today and will embrace these until they start causing us problems and then we'll throw those away and then we'll go back to the old ones you kind of referred to that when you talked about the days when we said if people hurt we shouldn't be letting them hurt we need to give them opioids control it and then we started to get the abuse and the deaths and and the pendulum swung and the other way and we sell we should be using opioids we should just use all the NSDS and it swings back and forth and back and forth and we just have to use our information we know what these things look like we know what the side effects look like we know it causes the side effects. If we're just prescribing and sending our patients home and expecting them to figure all this out on their own then I don't care what drug you give them there's going to be problems, we've got to be engaged we have to be talking we've got to know what their histories are and then decide which are the most appropriate drugs for the target the objective and for the background of our patients.

Howard: So you graduated from dental school you went to UCLA and now you're sitting in a according to the news a new 36 million dollar building, you made the newspaper University Utah celebrates new 36 million dollar dental school building tell us about the new dental school and how is it different than UCLA back in the day?

Glen: So UCLA was great and although they don't they're footballs not so good University Utah's footballs better but anyway it is it's a different time and this new school has given us the opportunity to look at the dentistry and its curriculum and particularly its relevance to the other primary care providers and comprehensive when we talked about comprehensive health and comprehensive care what role does oral health play in that whole discussion and so as dental school the university of Utah we are part of the university Utah a health care system. So we work very closely with primary care providers we have several off-site clinics throughout the state of Utah and those clinics for the most part have dentistry and primary care working shoulder-to-shoulder and so the physicians or the PA's or the nurses they'll see something they'll notice that there's an oral health issue and they'll bring the patients across the hall to us in dentistry or to the hygienist or we see something in our patients and we can just walk across the hall and take it to the medical care providers. We work very closely together and and we're starting to find that not only by working closely together do we serve the patient better but we also find that we complement each other in terms of our medical / dental objectives I don't think I don't think anybody would be surprised looking in the mirror to to realize that the mouth is part of the rest of the body unfortunately we sometimes practice as though it is we practice in a silo and we say oh no no we don't want to go anywhere further back in the mouth because that's really not our purview that's somebody else's or or the maxillofacial or primary care or pediatrician don't want to come into the because they feel like oh no that's totally off-base for us we shouldn't be going there we should be having these discussions amongst ourselves as to what we can contribute what they can contribute to us and visa versa and this kind of gets to a study that we had recently we called it the floss study, floss is an acronym for a grant we got from hersa the health resource Services Administration to study what happens when you provide comprehensive dental care to patients who are being treated for substance use disorder. So this is kind of the issue that I'm referring to that we shouldn't be treating their conditions as though these are totally separate they're not associated with each other but rather you should be treating them as though they're complementing each other and that you can get better outcomes in both areas if you treat both things together and so as I think most dentists or health provider oral health providers know that people who have substance use disorder generally many of them have major oral health problems which aggravate all of the difficulties are wrestling with as part of their su deep problems they're not employed they're unemployed they have very poor self-confidence they with draw they're isolated they feel as though there are total failures they're in total despair many of them contemplate things such as suicide because they don't see that there's any light at the end of this tunnel and there's no way that they can manage it or they can conquer it and so they just let their mouths go untreated some of the drugs they treat cause they're Estonia they do damage to the mouse and this worsens that condition they can't eat they've lost dentition, they hurt all the time because they've got infections they got root canals that need to be done they can't sleep at night. So malnourished a terrible self-image they don't have any work socially social outcast and a lot of this is coming out of the mouth and the things that have happened to the mouth and so we thought maybe if we could put these two areas together as part of therapy that you would get better outcomes in treating the substance use disorder. So we did that and that's this grant plus grant I gave us the wherewithal to do it so he took 300 patients had major SUD problems they had major oral health problems as well almost half of them or heroin so a really high proportion were heroin about 30% were meth methamphetamine but 20% were alcoholics about 10% were marijuana than the rest of them were odds and ends of other kinds of drugs. Very few of them were single drug users I mean it's unusual to find someone who has a major substance use disorder and they're only focusing on one drug most of them are poly substance abusers but they had their they had their primary drug and so we identified the primary drug so we brought him in took care and this was comprehensive dental and it wasn't just emergencies I mean we certainly took care of the emergency issues but we wanted to restore their mouths in the same way that any of us going into a dentist's office would expect. So they got the full complement the only thing we wouldn't or couldn't do for these patients was implants but we did everything else we did restorative we did periodontics we did endodontics we did all the oral surgery we did crown and bridge we did removable we did everything that they needed so at the end of the day after the treatment they walked out of that office and the mouth was back where it should be. We had this great big mirror as they as they could walk out of the where the clinic was into the waiting room there's this big mirror and most of them would stop at the mirror once the dental work was done and just give this great big smile they would look at the mirror and seeing what had happened the Transfiguration that had occurred to them. So we thought well this looks like this is really working well so we went to the SUD providers the ones were treated that were managing them and providing care for their substance use disorder we said what what does this look like in terms of other aspects of SUD, I mean they look like they're feeling a lot better about themselves when they're coming out after we take care of the oral health piece. So they went and they looked at their outcome assessments and this is when we found a dramatic effect in terms of SUD treatment outcomes they stayed in treatment two to three times longer the average treatment duration for major substance abuse of like heroin abuse or meth abuse was about three months, hundred days. If they were getting comprehensive dental care it approached a year so it went up dramatically we found out that employment went up dramatically when they left they were two to three times more likely to be employed if they had comprehensive dental care than that they didn't have comprehensive dental care they were two to three times more likely to get off of their primary drug of abuse so they were more much more likely to become abstinent and if they had had a history of homelessness before they came into treatment if they got comprehensive dental care literally homelessness disappeared when they left they left their SUD treatment and they finished the dental care they had a home they had a place to go they did not go back on the streets or under the viaduct so homelessness disappeared.

Howard: Where did you get the word floss participants what did you say floss stood for, locating a lifetime floss facilitating a lifetime of oral health sustainability for substance use disorder patients and Families?

Glen: That's it I never remember it, that's why I always call it floss but but if you tease those words out it that's kind of what it's talking about it's talking about what does it mean when you take care of oral health needs what does it mean as far as their substance use problem in a long-term way and our data suggests that it means a lot it really helps these people a lot.

Howard: Where is that study published?

Glen: That's in the Journal of American Dental Association, July issue of this year 2019.

Howard: Yep got it, yes comprehensive oral care I was just trying to connect the floss term comprehensive oral care improves treatment outcomes and male and female patients with high severity and chronic substance use disorder it is just such a complex issue isn't it?

Glen: It totally is and when I talked to people about this I've talked to dental groups and I've also talked to the Medicaid organizations across the country and one of the outcomes of this because the effects were so dramatic we took them to the state legislature legislature and we said we think that if we could provide comprehensive dental care to Medicaid patients who have cepsa Joos disorder issues they're being treated and we couple comprehensive dental care with that through the Medicaid program we're going to see the same kinds of outcomes in our Medicaid population and we got it through the legislature almost unanimously the Medicaid office said yes let's do it the federal Medicaid office when we sent a request to have it part of the federal Medicaid program they called us and said we've never heard of this before would you explain this to us as to what you're talking about and we said sure that we invited them to come to the dental school we'd show them they came they spend an afternoon with us and we had some floss patients down in our clinic that we're taking care of that day we took them down and introduced them to the floss patients, introduced them to the dental students and they just heard why a positive experience this was not only for the patients as you are totally changing their self-image and their outlook but also to the dental student who had a chance to see they were developing a skill set that could turn a person's life completely around. I mean we literally had stories about individuals who are going to commit suicide until they had an opportunity to have their oral health needs addressed and they did it and one lady she is an administrative assistant for the mayor's office of Salt Lake County I mean they got these high profile jobs they were trained people but they have gotten into drug problems and and they just drifted away from their skill sets and now that you've restored the mouth you've given them self-confidence you've given them a good quality of life they feel like they have the energy to address the drug abuse issues and they can put that life back together again. So it's been a very powerful lesson to our students that this is a place where you can really make a difference in people's lives.

Howard: It's a very interesting data you have there that the chart is a first step house self-declared self-declared methodology outcome doesn't seem like this is a very easy research at all. So tell us about the journey you you've you're on your twelfth edition of drugs and society I mean what a commitment I mean when did the first edition come out and will there be a thirteenth edition, can we make news on dentistry uncensored by announcing the 13th edition?

Glen: Well there will be another edition or working on that now but I started working with Jones and Bartlett is the publisher and this is around 1990 so we're almost into the 30th year of this and it turned out so I was in I was in the field I've been working drug abuse that neurobiology, wasn't doing much with dentistry because we didn't have a dental school at the University at that time so I was in the College of Pharmacy in the School of Medicine and in those days but I got a chance to do this book and it worked so well it was so well received that we just kept doing the next edition of the next edition in the next edition and it sells about 20,000 copies a year and it is used by two to three hundred universities across the country as their principal text in drug abuse and drug abuse and Society so it in a way it became an exercise of really immersing myself in all aspects of drug abuse because as a scientist the only thing I did was i injected rats I extract it or I took out their brains and I did neural chemistry and genetic analysis and looked at the effects of drug abuse. Working with this book and then later going back to the National Institute on Drug Abuse I had a chance to really see how drug abuse and society interacted in its many many aspects the public health piece and that and really set me up for coming back into the dental school and saying you know I can bring these two things together I can bring my background and drug abuse and my dentistry and that's how we got to the paper that we just talked about where we see there is a connection for dentistry as we try to deal with these other chronic diseases such as substance use disorder and now we're trying to sort out why now what is happening here when you take care of a person's oral health that makes their ability to deal with diseases like SUD much more effective and the outcomes to become more positive and we should as dentists, oral health providers we should be sitting at the table with the other health providers wellness providers talking about strategies talking about partnerships, talking about putting our skill sets together in order to provide better comprehensive outcomes for our patients.

Howard: So how is this how is this message being delivered to the new dental students or it's a new generation we always hear how different the Millennials are than the earlier generations like the Boomers is this how is this I this is pretty a complicated message to teach them?

Glen: It's not that complicated because we when we have a really good example in substance use disorder which is an in-your-face thing nobody questions that is this a problem is it not a problem because there's so many aspects of it where it is a problem and then we can take that as an example of an underserved population that has made your oral health challenges and bring them into our dental clinic which is sort of controlled we have our attendings, we have our students and we have our didactic instruction where we can kind of fill in gaps what they're not learning in clinic they can learn in the classroom and vice versa and so they can see a comprehensive approach to introducing them and their skill sets to what it is they're going to become or want to become when they walk out of the School of Dentistry here at the University of Utah with their DDS agree and they put together a practice what do I want to look like do I want to be working in Hollywood and working on movie stars for my entire career which was kind of my ambition when I came out of UCLA because UCLA was right up there and I actually as a student worked on a lot of movie stars not the big ones but I had a lot of movie stars I thought hey this is my idea of a practice but I didn't ever work on these patients it's underserved patients I never get that exposure we're giving that to our students and now they walk out and they say I've got a role to play out here I mean they want to make a living okay totally understand them but they all so have a skill set that can turn people's lives around in a way that they never quite understood before so they see it real life they see it and you can't teach better lessons than real life.

Howard: So when you you guys are very cerebral I mean you have a DDS PhD the Dean Wyatt Rory Hume has a DDS PhD when you guys decided to start a dental school in 2013 did you guys feel there was a need for a new dental school or that you didn't want some unique selling proposition in a country with so many dental schools what was the impetus to want to start a new school?

Glen: I think you hit it right on the nail right on the head we felt that there was something different that we could do at this one just because of the link with the rest of the university we were embraced by the Medical School, Pharmacy in nursing and the other health professionals because they felt there was a role for dentistry to play and quite frankly their health care system that was being administered by the University had very little dentistry there, we had a residency program a general practice residency program but that was it and they didn't have the experience dental students that are acting with medical students with pharmacy students and nursing students and as we went out and tried to create these off-site clinics to care for some of these underserved populations they were doing the same thing from the medical side and so we partnered and we put clinics together as a partnership instead of they did theirs and we did ours and we would invite them over for Christmas lunch and they would invite us over for Christmas lunch, we live together in the same building in the same clinic and we work together and so this was an opportunity to change and develop a model that we think is actually going to be the future of much of Dentistry as we go down this road they call it they call it bonding or blending where you blend the different services in a way that makes sense for wellness but also like fiscal sense you know if you talk to Medicaid you talk to Medicare or you talk to some of the insurance providers these days they are trying to find ways to to blend together comprehensive care rather than let's say about a cancer patient we know that we're going to be treating them they know we know they have oral health problems and so oftentimes the Cancer Center will send them to a dentist go to your dentist have your dentist take care of all this and then come back and we'll start the cancer treatment on you rather than sitting down with the dentist and said okay we're treating this cancer these are our concerns tell us what you think in terms of the oral health piece what do we need to keep in mind as we radiate or we do surgery or we give chemotherapy what sort of oral issues should we be mindful of and so the dentist's is right there with them all the way through this treatment and it's a patient that's the winner at the end of the day. So if you if you go to an insurance company and say we provide comprehensive care for this this cancer patient and it includes all of these things that are important for wellness the price tag will be this whatever that price tag happens to be but it covers all of these and it makes the provider is blend and think we as the dentist we know they're on chemotherapy we know it's going to compromise their immune system we know that their pain management's going to look different we know their nutrition is going to look different so that informs us so we can provide better dentistry for them and vice versa the patient's the winner.

Howard: The United States has a rich history in dental education I mean the first the world's first dental school was in Bainbridge Ohio in 1828 now it's a dental Museum the first dental college the world was Baltimore College of Dental Surgery in 1840 so now it's 2020 when we're supposed to all be seeing more clearly now in 2020 and yet Medicaid and Medicare dentistry it's not even part of the human body I mean do you think the dental schools, it's time that maybe the DDS and DMD degree should go back to the MD degree and they should get on the same train track or is a from 1828 to 2020 means it's almost 200 years 200 years of dentists being on one track United States has two hundred and eleven thousand Americans have an active license to practice dentistry and over a million have an MD degree do you think these two trains will ever get on the same track?

Glen: I think they will and I think that they are I don't know that it's necessary to think of ourselves as the physicians of the mouth I mean I have no particular argument against it but I think that it's important that our dental students be trained how to do clinical dentistry I'm a little nervous if there are those who feel that well we'll let the residency programs teach them the clinical dentistry piece of this and their undergraduate we will teach them the medicine physician piece of it. I don't think we're there and I'm not sure that we even need to go there do we need to give our students an excellent background in basic sciences and pathology and then diseases and in pharmacology yes I think we do because it's important, It's important to us to understand the effects of pathology and disease and pharmacology in the mouth as it is to an internal medicine doc or not the malla gist or any other professional or specialist but having said that I don't know that we need to be training dentists how to give cancer therapy or need to be training them how to do surgery and remove the gallbladder I'm not sure that's necessary I think the dental skills we give them clinical dental skills are sufficient and and worthy being included in the big discussion of the overall health of the patient. I think that what we need to be doing is one work closely and not be afraid of being part of comprehensive health discussions but I think we also need to show that when we decide is dental ever going to be a part of Medicare that we can come to the table hopefully what papers like what we've done and others will do and say you know what the literature says it says if we can provide comprehensive dental care to these Medicare patients and they have substance use disorder their response to treatment for the SUD is going to be dramatically improved. I personally believe that you'll see the same connection between comprehensive dental care and prediabetes comprehensive dental care and Alzheimer's disease comprehensive dental care and cardiovascular disease I think if you can give these patients that have these serious major chronic diseases good oral health so that they have good nutrition so that they feel good about themselves so that they feel they have contributions to make still we call it quality of life you give them a good quality of life through their oral health that you'll have a dramatic impact on the rest of their health and so we go to Medicare and we say this is what we're bringing we're gonna save you money on all these other diseases because they're going to get better faster and you're going to slow down the deterioration that caused by the disease, so we're gonna save you money and even more importantly we're going to help preserve and lengthen the health that your patients can have. We if we have the evidence we have that discussion guess what will be part of Medicare we are part of Medicaid but that varies from state to state so each state makes a determination. In our state the dental school the floss program but other pieces went up to the Medicaid and not only did we get our Medicaid program both of the state and the federal level not only did we get them to extend coverage dental coverage to Medicaid SUD patients but we also got them to expand comprehensive dental care or patients that have disabilities, so disabled patients so these are people that have diabetes they have degenerative diseases they can't work as a general rule and this year they have extended it to the elderly Medicaid. So our elderly in the state of Utah get comprehensive dental care as part of their Medicaid package you look at those together that's almost half of the medicaid adult population in the state of Utah get the very best dental coverage through the Medicaid program other states can do the same thing.

Howard: Well I'll tell you what I'm so glad you came on the show today this was so informative I've been wanting to get you on for so long this was just amazing Dr. Glen R Hanson DDS PhD professor and Dean University of Utah School of Dentistry, thank you so much for coming on the show today.

Glen: Thank you Howard, it was a pleasure.

Howard: Have a great day

Glen: Take care