Oral health, substance use, and mental health are closely interconnected. Understanding these connections enables you to support individuals more effectively and explains why someone may be experiencing dental issues alongside other challenges in their life.

Research has found that 27% of people experiencing homelessness use alcohol to cope with dental pain.¹ This behaviour is not a sign of weakness or a choice. Instead, it illustrates the following cycle:

Pain leads to self-medication → self-medication worsens oral health → deteriorating oral health causes even more pain.

This cycle is common and genuinely difficult to break.

This guide outlines how substances and mental health affect dental health and offers practical harm-reduction strategies. The goal is not perfection but rather to reduce harm and support individuals where they are.

How Substance Use Affects Oral Health

Alcohol

Alcohol affects oral health in several ways. It's important to understand these effects to support individuals effectively and without judgment.

1. Acid erosion. Alcoholic beverages, particularly wines and alcopops, are acidic. Heavy drinking can lead to vomiting, where stomach acid comes into contact with teeth. Over time, both the acidity of the drinks and the stomach acid erode tooth enamel, making teeth sensitive, discoloured, and fragile.
2. Dry mouth. Alcohol dehydrates the body and reduces saliva production. Since saliva protects teeth, having less saliva increases the risk of decay.
3. Cancer risk. Alcohol is a significant risk factor for mouth cancer,² and the risk is substantially heightened when combined with smoking.
4. Nutritional effects. Heavy drinking can lead to nutritional deficiencies that affect gum health and healing.

What helps:

• Drink water alongside alcoholic beverages.
• Wait at least 30 minutes to brush your teeth after vomiting, as brushing immediately can damage acid-softened enamel.
• Rinse your mouth with water after vomiting.
• Chew sugar-free gum to stimulate saliva production.

Opioids and Methadone

There is a common belief that methadone "rots teeth," but this is inaccurate. The damage stems from the effects of opioids on the mouth, not from methadone itself.

1. Dry mouth (xerostomia). Opioids significantly reduce saliva production, which is the main cause of increased decay among opioid users. Without enough saliva, acid attacks teeth for longer periods, leading to faster decay.
2. Sugar cravings. Opioids can increase cravings for sweet foods and beverages, contributing to the risk of decay.
3. Pain masking. Opioids can mask dental pain, allowing problems to go unnoticed until they become severe.

What helps:

• Chew sugar-free gum after taking methadone to stimulate saliva.
• Sip water throughout the day.
• Use saliva substitutes if dry mouth is severe.
• Choose sugar-free formulations of methadone where available.
• Schedule regular dental check-ups to catch problems early.

Stimulants (Cocaine, Amphetamines, MDMA)

Stimulants cause significant oral health damage through several mechanisms.

1. Dry mouth. Stimulants dramatically reduce saliva production, leading to rapid decay.
2. Teeth grinding (bruxism). Clenching and grinding can wear down teeth and damage jaw joints, especially with MDMA and amphetamines.
3. Rubbing on gums. Cocaine, when rubbed on the gums, can cause tissue damage, gum recession, and bone loss.
4. Reduced blood flow. Stimulants constrict blood vessels, limiting blood flow to the gums and slowing healing.
5. Neglected self-care. Heavy use can disrupt brushing and eating patterns.

What helps:

• Chew sugar-free gum to stimulate saliva.
• Use mouthguards to protect against grinding damage (consult a dentist for this).
• Avoid rubbing substances directly on the gums.
• Use lip balm for cracked lips.
• Return to a regular brushing routine as soon as possible.

Cannabis

Cannabis use is associated with oral health problems, although research is still ongoing.

1. Dry mouth ("cottonmouth"). Cannabis reduces saliva flow, increasing the risk of decay.
2. Smoking effects. Smoking cannabis can adversely affect gum health, similar to tobacco.
3. Increased snacking. The "munchies" often lead to cravings for sugary snacks, further increasing the risk of decay.

What helps:

• Sip water to manage dry mouth.
• Chew sugar-free gum.
• Choose healthier snacks where possible.
• Maintain a regular brushing routine.

Tobacco and Smoking

Smoking is one of the most significant risk factors for gum disease and mouth cancer.²

1. Gum disease. Smoking reduces blood flow to the gums, hides early warning signs (like bleeding), and impairs healing. Smokers are much more likely to develop severe gum disease and lose teeth.
2. Cancer risk. Smoking is a major cause of mouth, throat, and lip cancers.² The risk multiplies when combined with alcohol.
3. Staining. Tobacco stains teeth and dental restorations.
4. Slower healing. Smokers tend to heal more slowly after dental treatments and have higher complication rates.

What helps:

• Any reduction in smoking can be beneficial.
• Quitting smoking rapidly improves gum health.
• Access resources for smoking cessation.
• Avoid brushing immediately after smoking; wait at least 30 minutes.

Vaping

While vaping is less harmful than smoking, it can still impact oral health.

1. Dry mouth. The primary concern with vaping is dry mouth, as propylene glycol in vape liquids absorbs moisture.
2. Gum irritation. Some evidence suggests that vaping may irritate gum tissue.
3. Unknown long-term effects. Since vaping is relatively new, the long-term oral health impacts remain unclear.

What helps:

• Sip water to stay hydrated.
• Chew sugar-free gum.
• Maintain a regular brushing routine.
• Understand that switching from smoking to vaping still reduces overall health risks.

Mental Health and Oral Health

Depression

Depression can make self-care feel overwhelming. Even brushing your teeth may seem like a major effort when getting out of bed is a struggle. It's not laziness; it's a symptom of the condition.

Common patterns:

• Neglected brushing and flossing
• Comfort eating, often involving sugary foods
• Reduced motivation to attend dental appointments
• Feeling that dental health doesn't matter

What helps:

• Non-judgmental acknowledgement that self-care is difficult at the moment
• Any brushing is better than none
• Keeping a toothbrush in a visible spot as a reminder
• Breaking tasks into smaller, manageable steps

Anxiety

Dental anxiety is common and can be quite severe. For some, it may even develop into a phobia that prevents any dental care.

Factors that contribute to dental anxiety include past negative experiences, fear of pain, fear of judgment, and loss of control.

Signs someone may have dental anxiety:

• Avoiding dental appointments despite visible problems
• Showing visible distress when discussing dental issues
• A history of traumatic dental experiences
• Panic symptoms when thinking about dental visits

What helps:

• Acknowledging that the fear is real and valid
• Avoiding pressure until the individual is ready
• Finding dental services that specialise in treating anxious patients
• Discussing sedation options with a dentist
• Gradual exposure, such as visiting the practice without receiving treatment and meeting the dentist
• Accompanying someone for support

Trauma

For individuals who have experienced trauma, dental care can be particularly challenging.

Lying back in a chair, opening one's mouth, having someone lean over, and feeling a loss of control can all trigger trauma responses. Specific trauma related to oral care can make any dental procedure unbearable.

What helps:

• Access to trauma-informed dental services (some areas have specialised provisions)
• Giving the person control over the situation: they can stop at any time
• Agreeing on signals to pause treatment
• Sitting up rather than lying flat
• Providing explanations for every step before it happens
• Taking things very slowly
• Respecting if someone cannot engage with dental care at the moment

Psychosis and Severe Mental Illness

Oral health often deteriorates during episodes of psychosis or severe mental illness.

Contributing factors:

• Disrupted self-care routines
• Side effects of antipsychotic medications (e.g., dry mouth, sugar cravings)
• Difficulty attending appointments
• Symptoms that hinder effective communication

What helps:

• Providing support for practical oral care during episodes
• Ensuring that the side effects of medications are managed (e.g., using saliva substitutes)
• Assisting with appointment attendance when the person is well enough
• Collaborating with mental health teams to incorporate oral health into care plans

Eating Disorders

Eating disorders can lead to specific oral health problems.

For instance, vomiting frequently exposes teeth to stomach acid, which erodes tooth enamel, making teeth sensitive, discoloured, and fragile.

Nutritional deficiencies associated with eating disorders can also affect gum health and healing.

What helps:

• Rinsing the mouth with water after vomiting (avoiding immediate brushing)
• Using fluoride mouthwash
• Collaborating with eating disorder services to address oral health
• Offering sensitive, non-judgmental dental care

Medication Effects

Many medications can cause dry mouth, which increases the risk of tooth decay.

Common medications causing dry mouth:

• Antidepressants (SSRIs, tricyclics)
• Antipsychotics
• Antihistamines
• Blood pressure medications
• Opioid pain medications
• Methadone
• Some anti-epileptic medications

Managing medication-related dry mouth:

• Sip water frequently
• Sugar-free gum or lozenges
• Saliva substitutes (gels, sprays) are available from pharmacies
• Avoid caffeine and alcohol, which worsen dryness
• Use a humidifier at night if possible
• Tell your dentist about your medications

Supporting People with Complex Needs

Harm Reduction Approaches

Harm reduction means reducing the negative effects of a behaviour without requiring someone to stop completely.

For oral health, this means:

If someone is using substances:

• Sugar-free gum after using (especially after methadone)
• Drinking water between alcoholic drinks
• Not brushing immediately after vomiting (wait 30 minutes, rinse with water first)
• Maintaining any brushing routine, even if irregular

If someone is smoking:

• Any reduction helps
• Explore alternative nicotine replacements
• Signposting to stop smoking services when ready

If someone is experiencing depression:

• Any brushing is valuable
• Keeping supplies accessible
• Not adding guilt about self-care

The key message: Some care is always better than none. Progress doesn't have to be perfect.

Preparing Someone for a Dental Appointment

Before the appointment:

• Ask what worries them most
• Help them write down what they want to say
• Explain that dentists see people with complex needs regularly
• Offer to accompany them
• Discuss whether they want to mention their mental health or substance use (it helps the dentist understand their situation, but it's their choice)

At the appointment:

• Being there as support if wanted
• Advocating if needed (though let the person speak for themselves)
• Helping them understand what was said afterwards

After the appointment:

• Checking how it went
• Helping with any follow-up appointments
• Celebrating that they went, regardless of the outcome

Finding Appropriate Dental Services

Some dental services are better equipped to handle complex needs.

Community Dental Services often have more time and experience with anxious patients and people with complex needs.

Specialist homeless dental services exist in some areas. Ask your local homeless health team or Integrated Care Board.

Some general practices are particularly welcoming. Word of mouth from others who have attended can help identify these.

If services in your area aren't meeting needs, feed this back to commissioners.

Breaking the Cycle

Small Improvements Matter

Progress with oral health is often gradual. Celebrate:

• Someone accepting a toothbrush
• Brushing a few times a week
• Attending one dental appointment
• Choosing water instead of sugary drinks sometimes
• Chewing sugar-free gum after methadone

These are real achievements.

Oral Health as Part of Recovery

As someone's life stabilises, oral health often improves too.

Having a bathroom. Somewhere to keep a toothbrush. A routine that includes brushing. These become possible when other things settle.

Dental treatment can be part of recovery. Fixing painful or visible problems can boost confidence, improve eating, and help people feel better about themselves.

Some people want to address their teeth as part of a fresh start. Others need other things to stabilise first. Both are valid.

Working Together

Oral health is rarely a standalone issue. It connects to mental health, substance use, housing, and overall well-being.

Working with dental services, mental health teams, and substance use services together makes sense. Including oral health in care plans and health assessments helps.

When oral health is everyone's business, people get better support.

Quick Reference

Key substance effects:

• Alcohol: erosion, dry mouth, cancer risk
• Opioids: dry mouth, sugar cravings, masked pain
• Stimulants: dry mouth, grinding, gum damage
• Cannabis: dry mouth, snacking risk
• Smoking: gum disease, cancer risk, slow healing

Key mental health links:

• Depression: neglected self-care
• Anxiety: avoiding dental care
• Trauma: dental procedures as triggers
• Medications: dry mouth

Harm reduction essentials:

• Sugar-free gum stimulates saliva
• Water between drinks/after using
• Wait 30 minutes to brush after vomiting
• Some brushing is always better than none

When to Get Help

For urgent dental problems: Call NHS 111 or visit 111.nhs.uk

If someone has facial swelling with fever or breathing difficulty: Go to A&E

To find an NHS dentist: www.nhs.uk/service-search/find-a-dentist

For mental health crisis support: Call NHS 111, Samaritans (116 123), or local crisis team