Artists, dentists, public health experts and addiction workers have collaborated with people with lived experience of drugs to create a series of comics that examine the impact of substance use on oral health.

The University of Dundee, NHS Fife and the Scottish Drugs Forum came together for the Oral Health Improvement for People with Experience of Drugs (OHIPED) project. The comics they produced form part of a series of resources that will be used to deliver oral health mentor training to addiction workers and to raise awareness of the issues highlighted to improve access to services.

The involvement of people with a history of drug and alcohol use was central to the project and they related their lived experience with the help of the Scottish Centre for Comics Studies, which runs the Dundee Comics Creative Space project.

Drug use affects oral health through direct physiological routes but the lifestyle that often accompanies problematic drug use also affects oral health through high-sugar diets, malnutrition, poor oral hygiene, and lack of regular professional dental care.

Research from the University’s School of Dentistry has previously shown an increased prevalence of decayed and extracted teeth among people with substance use problems, who also reported increased embarrassment and stress regarding their appearance leading to poor self-esteem. They have poor experiences of accessing dental services and preventive dental care, with the stigma of past drug use increased significantly by poor oral health.

The project also addressed the fact that, rather than visiting their dentist to receive safe pain relief, individuals might choose to deal with toothache by self-medicating when they may already be taking a variety of other substances.

“Our co-designers told us that when they were using drugs they were not thinking about their oral health,” said Dr Niall McGoldrick of the University and NHS Fife. “In addition to the aesthetic impact of this, it obviously makes them more susceptible to infections and other oral health problems.

“A major concern is that when dealing with significant toothache or other problems, individuals may be tempted to take more drugs to deal with the pain. This is more likely to happen when people are disconnected from services and could increase the risk of overdose.

“This is one of the first studies to look at this issue, but we have substantial anecdotal evidence about the effects of prolonged or problematic drug use on an individual’s oral health.

“Participants told us that a passer-by might smile at them, but they didn’t feel they could smile back because they were embarrassed by the state of their teeth. They also felt uncomfortable accessing dental services because they felt they were being judged by clinicians, so we are also seeking to educate those working in the dental profession about how stigma prevents people from accessing treatment.

Professor Christopher Murray, director of the Scottish Centre for Comics Studies noted that “We have a lot of experience producing healthcare and public information comics, but this project was special as we were looking at a series of interrelated and complex issues, including oral health, drug use, and social attitudes towards these challenges. The team, which included Dr Damon Herd and comics artists Rebecca Horner, Andrew Strachan, Dr Olivia Hicks and Katie Quinn, did a great job of visualising the findings of the research and the experiences of the participants.”

Dr McGoldrick “We saw the comics as a novel way to communicate these messages as an adjunct to a wider oral health improvement programme. The stories are based on lived experience and each comic is designed around a particular theme. We need to engage more with this group and let them know about safe pain relief, how to access treatment and how to look after their family’s oral health.”

The OHIPED collaborators identified three overarching themes that were turned into comics:

· Dental health access when using drugs

· Looking after my dental health during recovery

· Looking after my family’s dental health

The comics covered safe pain relief, addressing dental anxiety, how to access dental services, and risk reduction. They were just one of several resources that volunteers with the SDF helped produce to share how their experiences with drugs and/or alcohol has impacted on their oral health.

All resources produced as part of the project will be used as part of a training programme to enable addiction workers to be advocates for oral health. Training was delivered to trainee addiction workers who provide care in recovery hubs, justice settings and homelessness support centres. The project partners also sought to develop the capacity of volunteers with a history of drug and/or alcohol use to undertake research. The collaboration was brought together by the late Professor Ruth Freeman to try and improve oral health amongst this group. The work was funded following a successful joint bid from the School of Dentistry and the School of Humanities to the Corra Foundation. The purpose of the programme is to reduce health inequality by addressing oral health as an indication and predictor of health and psycho-social functioning.

Previous public education comics created by writers and artists at the University’s Scottish Centre for Comics Studies have helped raise awareness of a range of conditions and issues including heart disease, coeliac disease, grief and organ donation and are available here: Public Information and Educational Comics.

You can learn more about the comics and oral health project here: https://www.dundee.ac.uk/projects/oral-health-improvement-people-experience-drugs