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Identifying methamphetamine use
2nd February 2010
When you look in your patient’s mouth, do numerous teeth have gingival buccal decay? Are molars ground to the gumline? If so, start asking questions, writes Sandra Nagel Beebe

Images
(click to enlarge)


Case B – maxillary left

Case B – maxillary right posterior

Case B – mandibular anteriors

Case B – mandibular left posterior

Case B – maxillary right

Case B – mandibular right

As Dr Stephen Wagner states: ‘What I can tell you is what I have seen. It looks like someone has taken a hammer to these teeth and shattered them’ (Davey, 2005; Broadway Dental News, 2007).

You need to treat the whole person, not just the decay. This is a difficult patient to treat, so know your parameters. 

Knowing the basic facts
US Attorney General Alberto Gonzales stated: ‘In terms of damage to children and to our society, meth is now the most dangerous drug in America.  We have a problem’ (Jefferson DJ et al, 2005). In 2008, the Survey on Drug Use and Health (NSDUH) reported more than 12.6 million Americans have tried methamphetamine, while 850,000 reported use in the past year (Office of National Drug Control Policy, 2008). 

Simply stated, methamphetamine is a drug that speeds up the nervous system and is highly addictive (Broadway Dental News, 2007; Office of National Drug Control Policy, 2008).
Various methods of consumption are available to meth users. It may be swallowed, inhaled/snorted, smoked or injected (Broadway Dental News, 2007). Initial reaction time depends on method and quantity used (Center for Addiction and Mental Health, 2009).

Methamphetamines can easily be manufactured with common shop-bought materials. In the United States laws are changing to limit accessibility to certain products used in methamphetamine production such as psuedoamphetamines (NACDS, 2007).

In 2005, Allison Colker stated: ‘Cold medicine manufacturers, in an abrupt change, are reformulating their products in a way that likely will cripple home meth labs, which account for 35% of illegal meth production. Drug companies are rushing to replace their pseudoephedrine-based products with the decongestant phenylephrine, which can not be made into methamphetamine.’

However, Tom McNamara, Director of Southern Illinois Drug Task Force, has said: ‘This legislation has decreased methamphetamine home labs but meth use still remains the same’ (2007). 

A new formula evolved in 2009, resulting in meth users producing their own small batches through a procedure called ‘shake and bake’. This process uses small amounts of over-the-counter cold pills containing pseudoephedrine, some household chemicals and a two-litre fizzy drink bottle. Amounts produced are limited and the method is hazardous, with possibilities of explosion and burns.

Methamphetamine is not a drug just manufactured for the United States or Mexico, but is spreading throughout the world. In 2008, Garda commissioner Fachtna Murphy warned new recruits about crystal methamphetamine, which was beginning to trickle into Ireland.

Knowing the user 
Rural dentists are finding meth mouth to be a growing problem. According to Saurino (2007): ‘Meth users will only present to a dental practice when their symptoms have become extremely painful and they can no longer eat or function normally’.
 
Users may experience prolonged depression or suicidal feelings (Merck Manual, 2007). Recovering meth addicts must be observed with caution due to emotional, physical and/or psychological changes. A recovering addict will face numerous barriers in attempting to regain their oral health due to the multitude of dental expenses involved on normally limited funds (Davey M, 2005).

For example, the Utah prison system has recorded an increase in dental care costs. Between 2003 and 2004, there was a 30% increase, with some patients on a two-month waiting list (Colker A, 2005). 

Along with dental problems, patients have numerous other difficulties. They include Sjögren’s syndrome, decreased appetite, increased thirst, weight loss, and the inability to sleep followed by days of continuous deep sleep (McNamarra T, 2007; Goodis M, 2007). Patients may also experience:
• Changes in their personality
• Depression
• Moodiness
• A sense of well being
• Hallucinations
• Violent behaviour
• Memory loss
• Limited short-term memory
• Paranoia
• Reactions similar to Parkinson’s disease
• Weakened blood vessels
• Increased blood pressure (and increased heart rate)
• Strokes
• Heart attacks
• Liver disease.

Physical signs may include sores, constant itching from the sensation of ‘bugs’ crawling under their skin (formication or meth mites), excessive talking, jerking or uncontrolled movements, convulsions, and grinding or clenching of the teeth and jaw.

Certain problems become associated with long-term use. It may cause uncontrollable anxiety or rage, panic attacks, insomnia, brain damage, loss of pleasure (loss of dopamine flow), twitching, impaired speech, severe depression, stroke and, ultimately, death.

What causes meth mouth?
Meth users have specific issues when it comes to the oral cavity. A common side effect of meth mouth is dental decay. Teeth are decayed to the gumline, with numerous teeth ‘blackened, stained, rotting, crumbling or falling apart’ (Broadway Dental News, 2007).

The exact cause of meth mouth is controversial, with two schools of thought coming to the fore. The main cause is believed to be either the acidic nature of the drug itself or the addicts’ high consumption of sugar-laden drinks to alleviate dry mouth (Broadway Dental News, 2007; Colker A, 2005).

Meanwhile, the psuedoephrine is causing excessively dry mouth, decreasing or reducing saliva. With decreased saliva at one-tenth of normal levels (Colker A, 2005), acids will erode enamel and cavities will form due to oral home care neglect (Davey M, 2005; Fitzgerald S, 2009; Anderson JP, 2008).

Another concern is the decreased flow of blood to the oral tissues, leading to problems in the mouth; necrosis takes place with these tissues (Merck Manual, 2007). Further problems such as paranoia and anxiety tend to cause individuals to clench and grind their teeth (Anderson JP, 2008; Goodis M, 2007), leading to cracks in their teeth and cleaving, which are classic signs of meth mouth.

Early signs 
Let us take a closer look at meth mouth. What are the early signs in the mouth? When performing an oral exam, dental professionals may observe buccal cervical cavities beginning to appear (ADA, 2009). Interproximal decay may be beginning. Watch the anterior teeth for dark spots appearing interproximal (Goodis M, 2007; MAPP-SD project, 2007). Smokers may have burns inside the mouth, sores and infections (MAPP-SD project, 2007). These are considered to be signs of oral or smoked methods of use. Oral health damage in IV users will be the result of long periods of neglect, increased consumption of carbohydrate-rich drinks and psychological stresses.

As time progresses, decay rates escalate because of the  continual physical and chemical insults on enamel surfaces, leading to tooth destruction and then tooth loss. If an addict quits, the existing problems in their mouths continue to weaken enamel structures (Goodis M, 2007; MAPP-SD project, 2007). Repair costs are generally too great for these patients, so that care is not provided. Patients may try to extract root tips with needle-nose pliers prior to attempting to get dentures (Goodis M, 2007; MAPP-SD project, 2007).

Case studies
Patients’ self-esteem is reduced as a result of missing or decayed teeth. Their mouths immediately identify them as current or past meth users (Faller MB, 2006). Working with these individuals is a slow process.

Case A involved a 32-year-old recovering female addict with three children and a boyfriend. Working as a farm hand, money was limited. The individual was noted as being very quiet and would not smile or show her teeth; her life was withdrawn and fragile. Periodic meetings enabled the subject to be discussed but she was not ready to seek help. These social visits were the optimal time to begin applying subliminal dental thoughts for future treatment. Even though her employer offered payment assistance, Case A declined treatment. After approximately seven months, Case A personally called to admit she needed help because she was embarrassed to be out in public due to her dental appearance.

Appointments were made to begin treatment. The first appointment involved taking a medical history, X-rays and photographs, plus probing and a dental exam by the dentist. A second appointment was scheduled but was cancelled on the day because of car problems. Payment was provided by the employer but no appointments were scheduled for treatment.

Case B was a 24-year-old male scheduled for an exam, X-rays and cleaning. The hygienist questioned what was happening to the anterior teeth, which had yellowish/black spots and rampant decay. Reviewing his health history indicated no medical problems. Through a process of elimination, basic questions led to the answer.

It is important to tell the patient that the questions are only to assist in treating their dental needs. Questions to consider asking include:
1. Do you suck on lemons and limes?
2. Do you consume a lot of sugary drinks? If so, how much and how often?
3. How often do you brush or floss?
4. Have you been using any recreational drugs?

With the last question, it is important that you assess how the individual will react. Watch facial expressions when asking the patient other questions. Meth use can produce a psychosis in which the person misinterprets others’ actions, hallucinates, and becomes unrealistically suspicious (Merck Manual, 2007).

If patient is a user, think about these safety rules:
1. Do not make any  movements that could be perceived as threatening and keep your distance
2. No bright lights
3. Move slowly
4. Slow your speech
5. Always keep your hands visible
6. Keep the user talking.

If you consider that asking the patient whether they are a drug user is too risky, do not ask. Remember, meth users do not think rationally. After the user reforms, it generally takes two years or so for the brain to begin healing to reason properly.

Case B stated he had quit meth the previous year. He used for one year and his mouth was in total disrepair and needed attention. Being concerned, he wished to educate others on the effects of meth and so photos were taken for this purpose (see images on the previous page).

Case C was a 25-year-old male who had used meth for at least four years and had only been out of a meth treatment programme for a few days. The patient showed up for one appointment – the screening examination. 

These are three ‘typical’ meth patients. They are not reliable. Depending on their state of mind, patients will show initially because of their euphoric high or desire to improve. When the patients come down, this is when one will see limited or lack of response to scheduled treatment. 

Conclusion
Meth addiction is very serious, may be life-threatening and affects everyone around the user. We must work with these individuals to change their ways through rehabilitation (Stop Meth Addiction, 2007). Patients need to understand that rehabilitation is a multi-phase, multi-faceted long-term process that takes many months, or even years, of treatment.

Have clinic names and phone numbers readily available for the patient to contact. Recommend topical fluorides, xylitol, lots of water, and provide education.

So wrote Woolston (2009): ‘Meth mouth is almost always treatable. Most addicts can regain their smiles with fillings, veneers or dentures for a fee. It may be the first step to recovering their lives entirely.’

Programmes are necessary to build self-esteem in these individuals. We need to help to protect their children and other innocent bystanders (Assail LA, 2005).

According to Woolston (2009): ‘Unfortunately, many methamphetamine users do not get dental care until they are either in jail or in a rehabilitation programme.’

Sadly, by then their teeth may be gone or will soon be gone. 

References
American Dental Association (2009) Dental topics A-Z: methamphe­tamine use. At: http://www.ada.org/prof/resources/topics/methmouth.asp

Anderson JP (2008) Garda chief warns of crystal meth scourge. Drugs and Crime Plus General News. At: http://www.boardsie.com/forum/blog.php?b=203

Assail LA (2005) Methamphetamine: an epidemic of oral health neglect, loss of access to care, abuse and violence. Journ Oral and Maxillofacial Surg 63(9): 1253-1254

Broadway Dental News (2007) Rise in meth mouth: a growing concern for rural dentists. Available at: http://www.broadwaydental.org/riseinMethMouth.asp

Center for Addiction and Mental Health (2009) Information about crystal meth. Available at: http://www.camh.net/About_Addiction_Mental_Health/Drug_and_Addiction/crystal_meth_information.html

Colker, A (2005) National Conference of State Legislatures. Available at: http://www.ncsl.org


Common Sense for Drug Policy (2009) Methamphetamine focus. meth in America: hype or crisis? Available at: http://www.csdp.org/news/news/methupdate.htm

Davey M (2005) Grisly effect of one drug: meth mouth. Available at: http://www.nytimes.com/2005/06/11/national/11meth.html?ei=5088&en=d2ce61d667005

Faller MB (2006) Fortune smiles on ex-addict with ‘meth mouth’. Available at: http://www.azcentral.com/specials/special49/articles/0421/methmouth22.html

Goodis M (2007) Crystal methamphetamine – the wrong road. Available at: http://mitchtv.net/

Jefferson DJ et al (2005) America’s most dangerous drug. Newsweek 146(6): 40-8

MAPP-SD (2007) Meth awareness and prevention project. A project of Prairie View Prevention Services, Inc. Available at: http://www.mappsd.org/Long%-%20Short%20Term.htm

McNamara T (2007) Interview with Tom McNamara, Director Southern Illinois Drug Task Force

Merck Manual (2007) Amphetamines: drug use and dependence. The Merck Manual of Diagnosis and Therapy. Section 15, chapter 195 – Psychiatric disorders. Available at: www.merck.com/mmpe/print/sec15/ch198/ch198c.html

Office of National Drug Control Policy (2009) Methamphetamine facts and
figures
. Available at: http://www.whitehouse drugpolicy.gov/drugfact/methamphetamine/index.html

Peterson, D (2009) Drug use and oral clues. Family Gentle Dental Care. Available at: http://www.dentalgentlecare.com/drug_use_&_oral_clues.htm

Saurino, J (2006) Managing meth in your practice. The Spit – ASDA at The University of Colorado School of Dentistry. Available at: http://www.the-spit.org/fall06/meth.html

Stop Meth Addiction (2007) Meth rehab. Available at: http://www.stopmethaddiction.com/meth-rehab.htm

Woolston C (2009) Meth mouth. Among the horrors of methamphetamine addiction – losing your teeth. Caremark Health Resources. Special Report. Available at: http://healthresources.caremark.com/topic/methmouth



Author

Sandra Nagel Beebe

Sandra Nagel Beebe RDH PhD is a senior lecturer in the Dental Hygiene Bachelor’s Degree Programme and the co-ordinator for the Healthcare Management Internship Programme at Southern Illinois University Carbondale, Illinois. She has taught second- and third-year clinics, serves as the department’s assessment report co-ordinator, and monitors final-year rotations at a rehab and care centre. Sandra’s research interests include geriatrics and baby boomers, xylitol, methamphetamine abuse, smoking cessation, and treating patients with cancer.


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