The Oral Clues
Iowa program targets dental offices in the fight to identify and prevent drug abuse.
by Cathy Hester Seckman, RDH
Red phosphorus, muriatic acid, lithium from batteries, and anhydrous ammonia are not things the ordinary person would put into their mouth, but can you imagine what would happen?
If it didn't kill you first, it would certainly corrode your teeth away to nothing. Who would do such a thing? The simple answer, of course, is drug abusers.
The Iowa Health System's Community Initiatives in Healthcare — a community-based organization of physicians, hospitals, civic leaders, and local volunteers — has begun a program to recognize and prevent drug abuse, particularly methamphetamine abuse. The organization works on three levels:
• Educating pre-school children
• Hosting conferences for high school athletes
• Providing materials to primary care physicians and dentists to help them recognize methamphetamine users.
Because there are oral manifestations of meth abuse, dental offices are particularly targeted. David Weis, MD, director of the Powell Chemical Dependency Center in Des Moines, Iowa, sees addicts and users whose mouths are all but destroyed by the toxic chemicals in methamphetamine smoke.
"It's one of the hallmarks of chronic drug abuse to see some real big teeth problems," he says. "Basically, if you see a lot of tattoos and not many teeth, you gotta wonder (if they're using drugs)."
The oral problems all start with methamphetamine manufacturing. "A lot of it is made on a local basis," Dr. Weis said. "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."
When a meth lab is discovered, special law enforcement agencies have to detoxify the site because it's so volatile and fire-prone, Dr. Weis said.
There are several ways to use methamphetamine. Sometimes meth is injected intravenously, and causes no dental problems. "Nasal insufflation, or 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."
But the main way corrosion happens, Dr. Weis said, is when drug users smoke crystal meth in a pipe or tin foil. "They put heat to it, and inhale the vapors across the anterior teeth. The whole mouth is bathed in fumes. Enamel is essentially exposed to some very corrosive compounds. No matter how it's prepared or sold, there's always some residual unreactive phosphorus and anhydrous ammonia. Chronic meth smokers have teeth rotted to the gumline.
"If a hygienist sees 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, but these (drug users') teeth literally corrode away."
In his experience, Weis says, 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. But we've also had some 60-year-olds, and some 8- or 10-year-olds."
The red flags for alcohol/drug abuse include the following observable symptoms:
• Tremor, perspiring, tachycardia
• Slurred, rapid speech
• Dilated or pinpoint pupils
• Persistent cough
• Skin lesions on face, arms, and legs
• Unexplained weight loss
• Inflamed, eroded nasal septum
• Track marks/injection sites
• 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
• Suicide talk/attempt, depression
Our obligation in a dental office, Dr. Weis says, is to encourage medical evaluation. "This isn't the same as required reporting of physical or sexual abuse. You don't have a legal responsibility, but the patient will benefit if you try to facilitate an intervention. Ask some questions, and if they admit drug abuse, call the local treatment center."
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.
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
What happens to meth users
Back in the '60s, methamphetamine was called speed or crank. Other street names for it are crystal, 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.
Meth is used in pill or powdered form, and can be injected, snorted, or smoked. Even a first-time user can become addicted, and can experience damage to their body that can never be repaired.
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.
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.
Cathy Hester Seckman, RDH, is a frequent contributor who is based in Calcutta, Ohio. She can be contacted at cseckman @raex.com.