Drug Use & Oral Clues

Over 12 million people age 12 and older reported that they have used methamphetamine at least once i their lifetime.+ Meth has been identified as one of the MOST destructive substances to affect oral health in recent years.

The rampant decay seen in meth mouth is can be attributed to lack of a user's concern about oral hygiene combined with drug induced dry mouth, teeth grinding and a craving for carbohydrates and sweets.

One of the hallmarks of chronic drug abuse to see some real big teeth problems. It can be described as blackened, stained, rotting, crumbling or falling apart teeth. Often, the teeth cannot be saved and must be extracted.

The oral problems all start with methamphetamine manufacturing. The primary compound is anhydrous ammonia, and it includes some very corrosive substances, like red phosphorus, lithium from batteries, and muriatic acid. Mix all those together and you have some pretty caustic stuff.

There are several ways to use methamphetamine:

	If injected intravenously, it causes no dental problems.
	Nasal snorting, causes some enamel problems because the substance goes down to the posterior nasal pharynx, drains in the back of the throat and bathes the teeth with corrosive substances.
	Chronic meth smokers have teeth rotted to the gumline. "If you see extensive erosive enamel in relatively young people, you have to raise the question of whether meth is involved. There are plenty of reasons why teeth decay, however drug users' teeth literally corrode away. " Ether, benzene, Freon and paint thinner are extreely dangerous materials used in meth that affect dental health. It also greatly increases bruxism.
	Many meth users also have cutaneous manifestations — excoriations and sores on the face, arms, and legs. "What happens is they have visual, auditory, olfactory, and tactile hallucinations. They feel like there are bugs under their skin, so they scratch. Part of it may also be an allergic or chemical reaction. If you see corrosion of the enamel along with skin changes, the index of suspicion has to be relatively high.
	Behavioral changes you might also see include depression and paranoia.
	The demographic is a Caucasian male or female, typically between 19 and 30.

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&
For more pictures of Meth Mouth: Meth Mouth Pictures

Meth Mouth ADA Handout

The red flags for alcohol/drug abuse include the following observable symptoms:

Tremor, perspiring, tachycardia
Slurred, rapid speech
Dilated or pinpoint pupils
Persistent cough
Gray-stained plaque buildup on teeth
Large number of cracks on teeth
Skin lesions on face, arms, and legs known as formication. The sometimes characteristic scabbing that you see on meth addicts (particularly their arms) is caused by formication. There is a feeling of "ants crawling" on the arms and legs and "biting" them so they pick at the area sometimes breaking the skin and leaving numerous scabs. It comes from the fact that ants inject formic acid when they bite. (David IDF10.05)
Unexplained weight loss
Inflamed, eroded nasal septum
Track marks/injection sites
General pattern as the black decay...large number of cavities...after a year of use, dentures are the only option for many users!
Frequent falls, unexplained bruises, or fractures
Non-responsiveness to treatment for diabetes, elevated blood pressure, or ulcers
Frequent hospitalizations
Prescription drug-seeking behavior
Marked change in habits, friends
Increased sensitivity to noise
Poor hygiene...body odor (possibly a chemical smell)
Irregular heartbeat
Chest pain
Elevated temperature and excessive seating
Shortness of breath
Nausea, vomiting, diarrhea,
Dry mouth
Blurred vision
Dilated pupils
Intense paranoia
Suicide talk/attempt, depression
Possible auditory and visual hallucination
Impaired perception in thought process
Occasional episodes of sudden and violent behavior
Tendency to become compulsive
Increase in physical activity levels...Possibly "high strung".
The sores on the arms are from something called "formication" . The feeling that ants are crawling on them and biting them. They pinch at the area causing bleeding to bruising.

Our obligation in a dental office is to encourage medical evaluation. You don't have a legal responsibility to report drug use, but the patient will benefit if you try to facilitate an intervention. Since we are in an area where methamphetamine use is widespread, it doesn’t hurt to admonish every patient to avoid its use. Research shows that brief interventions by professionals that may be as simple as admonitions not to start or continue to use a substance or to decrease the amount and frequency of use can be very effective. You may also ask some questions, and if they admit drug abuse, call the local treatment center.

Meth and cocaine use can negatively interact with dental drugs. For that reason, dentist should be cautious when administering local anesthetics, sedative, general anesthesia or nitrous oxide or when prescribing narcotics .+

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Questions for an adult patient

1. Have you ever felt you should cut down on your drinking or drug use?
2. Have people annoyed you by criticizing or complaining about your drinking or drug use?
3. Have you ever felt bad or guilty about your drinking or drug use?
4. Have you ever had a drink or drug in the morning to steady your nerves or to get rid of a hangover?
5. Do you use any drugs other than those prescribed by a physician?
6. Has a physician ever told you to cut down or quit use of alcohol or drugs?
7. Has your drinking/drug use caused family, job or legal problems?
8. When drinking/using drugs, have you ever had a memory loss?

Questions for a teenage patient

1. When did you first use alcohol/drugs on your own, away from family/caregivers?
2. How often do you use alcohol/drugs? Last use?
3. How often have you been drunk or high?
4. Has your alcohol/drug use caused problems with your friendships, family, school, community? Have your grades slipped?
5. Have you had problems with the law?
6. Have you ever tried to quit/cut down? What happened?
7. Are you concerned about your alcohol/drug use?

Questions for a parent/caregiver

1. Do you know/suspect your child is using alcohol or other drugs?
2. Has your child's behavior or mood changed significantly in the past six months: sneaky, secretive, isolative, assaultive, aggressive, hostile?
3. Has your school, community or legal system talked to you about your child?
4. Has there been a marked fall in academic/extracurricular performance?
5. Have you noticed a change in your child's friends or peer group, or found any drug paraphernalia?
6. Do you believe an alcohol/drug assessment might be helpful?
Source: Iowa Health System

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Another danger of drug abuse: cavities, gum disease

Meth use causes "Meth mouth"
The first signs of meth use is to the teeth.

"Meth mouth". The toxic and caustic ingredients involved in the making of the meth—which includes anhydrous ammonia (farm fertilizer), lithium (from batteries), and lighter fluid, among other ingredients which are very acidic causing very aggressive erosion of enamel; decay formation; destructive to both tooth structure and restorative materials and damages to gums and oral tissues. The oral effects of methamphetamine use can be devastating. The acidic nature of the drug and dry mouth. Meth mouth causes:

	great deal of tooth decay- distinctive caries pattern often seen on the cheek side, smooth surface of the teeth and the in between surfaces of the anterior teeth due to acidic nature of the drug. Crank decay invariably starts at the gum line - it eventually spreads around the entire tooth.
	gum disease Meth causes the vessels that supply blood to oral tissues to shrink up. Reduced blood supply causes tissues to break down. With repeated shrinking, the blood vessels don't recover and tissues die.
	cracks in the teeth...because the drug can make them feel anxious or nervous, causing them to clench or grind their teeth
	dry mouth-Meth dries out the salivary glands.....it reduces the amount of protective saliva around the teeth
	bruxism-tooth grinding
	clenching
	poor diet-high calorie carbonated beverages...Meth users are notorious for trying to treat "cottonmouth" with lots of sugary soda.
	poor oral hygiene-Meth users are not likely to floss, brush and rinse when high.

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What happens to meth users....for dental professionals

Back in the '60s, methamphetamine was called speed or crank. Other street names for it are crystal, meth, speed, chalk, blue cheer, ice, glass, or blue. Meth is popular in the Midwest today because it is inexpensive and easily manufactured with over-the-counter ingredients. The allure of this drug is that it is cheap, easy to make and the high lasts much longer than crack cocaine (12 hours versus one hour for cocaine).

Meth is used in pill or powdered form, and can be injected, snorted, or smoked or taken orally. It is a bitter tasting powder that readily dissolves in beverages. Another common form of the drug is a clear, chunky crystal. This is the form known as “ice” or “crystal meth” and it is smoked in a manner similar to crack cocaine. Methamphetamine can also be in the form of small, brightly colored tablets. The pills are often called by their Thai name, yaba. Even a first-time user can become addicted, and can experience damage to their body that can never be repaired.

Mechanism of action-Methamphetamine stimulates release and blocks re-uptake of neurotransmitters called monoamines (dopamine, norepinephrine and serotonin) in the brain. Several areas of the brain are affected: the nucleus accumbens, prefrontal cortex, and striatum.

After the first hit, users get a surge of energy and confidence, and can go for long periods without eating or sleeping. As the hit wears off, they can feel jittery, anxious, and paranoid for days, hearing voices and having hallucinations. In the most common hallucination, users feel "crank bugs" crawling on their skin. Depression and suicidal tendencies are frequent symptoms of withdrawal.

Cerebral effects-by altering the levels of neurotransmitters in the brain, methamphetamine causes feelings of pleasure and euphoria. Methamphetamine is a neurotoxin and potent stimulant, which can also cause cerebral edema and hemorrhage, paranoia and hallucinations. Short-term effects include insomnia, hyperactivity, decreased appetite, increased respiration and tremors. Long term effects can include psychological addiction, stroke, violent behavior, anxiety, confusion, paranoia, auditory hallucination, mood disturbances, and delusions¹. Methamphetamine use can eventually cause depletion of monoamines in the brain, which can have an effect on learning.

Systemic effects-With high doses there may be an increase in both systolic and diastolic blood pressure due to cardiac stimulation. In addition, methamphetamine may produce arrythmias. Other systemic effects include: shortness of breath, hyperthermia, nausea, vomiting and diarrhea

Physical effects of long-term use include body odor, corroded teeth, open sores from scratching, sleeplessness, extreme weight loss, blurred vision, convulsions, and irreversible damage to the blood vessels of the brain that causes strokes.

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Methamphetamine User Profile

Traditionally, methamphetamine use has been most pronounced among males between the ages of 19 and 40. Methamphetamine use is increasing among college students and young professionals involved in the club scene or participating at rave parties.

Who is using meth?

	Adolescents and college kids, looking for that powerful high and a good time
	High-achieving high school and college students wanting to cram more hours into the day
	Women who love the way meth takes away their appetite
	Moms looking for a way to “do it all” really fast
	Long-haul truck drivers needing to stay awake
	Professionals under pressure to do more and more (e.g., lawyers, CPAs in tax season, medical residents on night call)
	Gay men looking to kick up the sexual thrill to a new high
	The bored, lonely, angry, depressed: looking for a way to feel better
	It could be almost ANYBODY

12.3 million Americans age 12 and older had tried methamphetamine at least once in their lifetimes (5.2 percent of the population), with the majority of past-year users between 18 and 34 years of age. Traffickers have aggressively targeted rural areas in an effort to escape law enforcement, and most use is found in the western, southwestern, and midwestern U.S

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What we will look out for:

	Unaccounted for and accelerated decay
	Distinctive pattern of decay on the buccal smooth surface of the teeth and the interproximal surfaces of the anterior teeth.
	Malnourished appearance

Protocol:

	Complete a comprehensive oral examination that includes taking a thorough dental and medical history.
	Express concern regarding the dental findings
	If the patient is receptive to a medical consult, have the phone number of a local physician, clinic or substance abuse rehabilitation facility, inform you what to expect at this facility
	Use preventive measures such as topical fluorides.
	Encourage consumption of water rather than sugar-containing carbonated beverages.
	Caution will be used when administering local anesthetics, sedatives or general anesthesia, nitrous oxide, or prescribing medications
	Education about the risks associated with methamphetamine or any illicit drug use****
	The speed and extent of decay from meth use is largely dependent on the user's habits and the frequency of dental visits. A lot of times our only choice is to extract the teeth and give them full upper and lower dentures.
	Glass ionomer restoratives with fluoride release for recovering addicts.#
	Acrylic partial dentures because if more teeth are lost another tooth can easily be added to the denture. # #AGD Impact, November, Volume 33, Number 10

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Updates

General and oral health implications of cannabis use.

Cannabis, commonly known as marijuana. There are three main forms of cannabis: marijuana, hash and hash oil, all of whichcontain the main psychoactive constituent delta-9- tetrahydrocannabinol (THC).
Cannabis is most commonly smoked, however it can be added to foods. THC from cannabis enters the bloodstream and exerts its effects on the body via interaction with endogenous receptors. Cannabis affects
almost every system of the body, particularly the cardiovascular, respiratory and immune systems. It also has acute and chronic effectson the mental health of some users.

Cannabis abusers generally have poorer oral health than non-users, with an increased risk of dental caries and periodontal diseases. Cannabis smoke acts as a carcinogen and is associated with dysplastic
changes and pre-malignant lesions within the oral mucosa. Users are also prone to oral infections, possibly due to the immunosuppressive effects. Dental treatment on patients intoxicated on cannabis can
result in the patient experiencing acute anxiety, dysphoria and psychotic-like paranoiac thoughts. The use of local anaesthetic containing epinephrine may seriously prolong tachycardia already induced by an acute dose of cannabis.Oral health care providers should be aware of the diverse adverse effects of cannabis on general and oral health and incorporatequestions about patients' patterns of use in the medical history.

Cho CM, Hirsch R, Johnstone S. Canibus and oral health Aust Dent J. 2005 Jun;50(2):70-4.

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Losing Teeth Latest Meth Use Side Effect

Jeffery Lotshaw flossed regularly. He brushed faithfully, sometimes four or five times in a day.

All that care makes his condition seem incomprehensible -- at the age of just 33, Lotshaw's grin is toothless. His teeth all broke apart, tarnished with yellow and black. "Before I started doing meth, I didn't have a cavity in my head," .

The growing use of highly addictive methamphetamine throughout the country is creating a prominent scar on an increasing number of users-- rotting, brittle teeth that seem to crumble from their mouths.

Methamphetamine can be made with a horrid mix of substances, including over-the-counter cold medicine, fertilizer, battery acid and hydrogen peroxide. Together, the chemicals reduce a user's saliva, which neutralizes
acids and physically clears food from the teeth.When the saliva isn't flowing, the bacteria build up a lot faster,"

Meth users also may neglect their teeth, or moisten their dry mouths with high-sugar drinks, and anxiety caused by the drug prompts them to grind their teeth, which speeds decay. They're rotting teeth, missing teeth, rotting way into the gums,". Lotshaw has been drug-free for more than five months, but there's nodenying what is to blame for his empty mouth.

By MATT SEDENSKY Associated Press Writer Originally published February 5, 2005, 2:03 PM EST

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Meth's Sexual Effect Explains Addictions

At a recent task force meeting on the epidemic of methamphetamine use in Appalachia, Gov. Phil Bredesen winced when a federal prosecutor described the illegal drug as an aphrodisiac. Doctors and government officials don't like to talk much about it, but there is an obvious reason people get hooked on methamphetamine: sex.

Meth eventually destroys the sex drive, but for a short while it can boost sexual appetite and performance more powerfully than drugs such as cocaine, doctors say.

Use of the addictive drug can cause brain damage, violent behavior and hallucinations, and exposure to the potentially explosive vapors during the manufacture of meth can cause respiratory problems, headaches and nausea. In many gay clubs in New York City and elsewhere, meth is often injected, putting users and their partners at risk for HIV, hepatitis C and other sexually transmitted diseases.

Sex is the No. 1 reason people use it. The effect of an IV hit of methamphetamine is the equivalent of 10orgasms all on top of each other lasting for 30 minutes to an hour,with a feeling of arousal that lasts for another day and a half,.

The effect doesn't last long. After you have been using it about six months or so you can't have
sex unless you are high. After you have been using it a little bit longer you can't have sex even when you're high. Nothing happens. It doesn't work." Meth and other stimulants initially "rev up the dopamine nervous system in the brain. They rev it up and burn it out.

A National Institute on Drug Abuse survey on drug use and health in 2002 found that 12.4 million Americans at least 12 years old -- or about 5 percent of the population -- had tried meth at least once in
their lifetimes.

"All substance abuse is frequently marketed as enhancing sex life or making you more attractive or a better social companion," said John Walters, the drug czar for President Bush. But he added that buying meth as an aphrodisiac is "buying under false pretenses." "Hair falls out. Teeth fall out," Walters said. "That's not sexy."

By BILL POOVEY Associated Press Writer December 3, 2004, 1:51 PM EST Mothers Against Methamphetamine: http://www.mamasite.net

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Addicts Pose Dental Risk

Drugs such as cocaine, methamphetamine and ecstasy have been shown to have dangerous interactions with common dental anesthetics. These, in turn, could cause major hypertensive episodes or other health problems. Heavy drinkers could have liver problems that could make it dangerous to use certain pain relievers, such as acetaminophen. The signs to look for drug use include severe tooth decay, gum disease, mouth sores, ulcers, stained teeth and broken teeth from drug- induced grinding.

In 2002, an estimated 22 million Americans- almost 10 percent of the population-suffered from chemical dependence or abused drugs, alcohol or both, (according to the latest statistics from the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services) Illicit drug use is highest among adults 18 to 25 years old, with more than 20 percent reporting they use drugs. Nineteen and a half million Americans-8.3 percent of the population ages 12 or older- reported using illicit drugs; 54 million reported participating in binge drinking in the previous 30 days; and 15.9 million considered themselves to be heavy drinkers.

AGD Impact, Dec 2003, Vol. 33, No. 9

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+Dental notes Winter 2005 1/06 pg 1

Meth Cost

RDH November, 2002 Author(s) : Cathy Hester Seckman, David Weis, MD, director of the Powell Chemical Dependency Center in Des Moines, Iowa

Sources for additional information include the following:

• The Iowa Health System's Community Initiatives in Healthcare program offers a toolkit to health care providers that includes a 19- minute video which describes how to approach, talk to, and help suspected drug users. Also in the toolkit are sample brochures and in- office aids such as posters, information cards, and signs. The kit can be ordered at the Iowa Health System Web site, www.physi cianssource.com.

• The Department of Education offers a free guide, "Growing Up Drug- Free: A Parent's Guide to Prevention" by calling (877) 4ED-PUBS. The full text of the 46-page publication is at www.ed.gov/offices/ OESE/SDFS.

• Other resources include the American Council for Drug Education, (800) 488-DRUG, www. acde.org; the National PTA Drug and Alcohol Abuse Prevention Project, (800) 307-4782, www.pta. org; the National Institute on Drug Abuse, (301) 443-1124, www.nida. nih. gov; and Partnership for a Drug-Free America, (212) 922-1560, www. drugfreeamerica.org.

& 'Meth Mouth' Strains

***http://www.ada.org/prof/resources/topics/methmouth.asp

Dr. Peterson web information being used here.

http://www.utmem.edu/dentistry/CE/Meth%20Mouth.NWms.pdf

Resources

Visit these links at the National Institute on Drug Abuse Web site:

	http://www.nida.nih.gov/Infofacts/methamphetamine.html
	http://www.drugabuse.gov/PDF/RRMetham.pdf

Find Out More
Online: http://www.ada.org/prof/resources/topics/methmouth.asp
http://www.nida.nih.gov/DrugPages/Methamphetamine.html
http://www.dea.gov/concern/amphetamines.html
http://www.nida.nih.gov/DrugPages/DrugsofAbuse.html

http://csat.samhsa.gov/.

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February 06, 2008