Treat Addiction? Begin with Teeth.

This is a short unpublished editorial on health policy in Massachusetts, though its main points are also applicable elsewhere.

When we think about addiction treatment, we think of hospitals, rehabs, and jails. But it turns out that if we want to promote recovery in Massachusetts, the place to do it may be in an unexpected one: the dentist’s chair.

The evidence comes from a remarkable project begun in Salt Lake City in 2015. Dentists at the University of Utah Dental School, and their students, provided free comprehensive dental care to residents at two local halfway houses.

That’s all. They simply provided all dental care that these residents needed: cleanings, root canals, restorations. The cost came to $1,236 per patient. (For comparison: the cost of a five-day drug or alcohol detox is typically several thousand dollars).

The results were almost miraculous. Patients receiving dental care were over three times as likely to complete addiction treatment than those who did not. They were over twice as likely to be employed after discharge from treatment. And they were over twice as likely to remain abstinent after the end of treatment.

These changes did not come from providing any additional therapy or medication. These patients received the same treatment as everyone else. All that they received, in addition, was adequate dental care.

Why did this work? There are probably a few reasons.

First, inadequate dental care has a familiar and predictable result: pain. Tooth decay hurts. Lacking adequate dental care, people in early recovery naturally turn to a reliable and available pain-killers: heroin and other opiates. Providing dental care takes away one reason for relapse.

Second, inadequate dental care has another result: visibly poor teeth. If someone is in early recovery and is interviewing for a job, applying for an apartment, or just going on a date, their teeth are a visible reminder of their past. Providing comprehensive dental care lets people move forward with their lives.

Third, people in recovery from addiction need the same things that everyone needs: stable housing, groceries, and social supports. This is what experts call “recovery capital” – the material resources that promote recovery. And part of recovery capital is simply adequate dental care.

Therefore, if we want a cost-effective and innovative way to treat addiction and promote recovery, we should think about teeth. And we should think about what kind of dental care people in early recovery are actually getting.

The people in the Utah study were fortunate to be participants in a program that provided most of the dental care they needed, at no cost. Most people in early recovery are not so fortunate. What does dental care look like for them?

In Massachusetts, it could be much better. Many people in early recovery lack private dental insurance and receive their dental benefits through MassHealth. This poses three problems.

First, there is the problem of actually finding a dentist: the most recent statewide oral health report indicates that only one-third of licensed dentists accept MassHealth. This problem is compounded by the current closings and restrictions due to COVID-19.

Second, MassHealth dental benefits are not always well-publicized, and many MassHealth patients fail to take advantage of the services that are available to them – such as two cleanings per year.

Third, even for patients who do find a MassHealth dentist and aware of the benefits available to them, the services actually provided fall well short of comprehensive care. MassHealth covers fillings and extractions (tooth-pullings), but it covers few of the more expensive methods that modern dentistry uses to restore teeth to their natural appearance, such as crowns. It even fails to cover treatments that most of us would consider basic, such as root canals.

This austere approach to oral health is short-sighted. A slight expansion in MassHealth benefits – to include, at a minimum, root canals and crowns – along with psycho-education on the benefits and availability of oral health care, could have a real impact on the treatment of addiction in Massachusetts.

This is the surprising significance of teeth. A modest expansion of state dental benefits is certainly one of the more surprising ways to promote recovery in Massachusetts – but it may turn out to be one of best.