Survey pinpoints concerns dental professionals have about treating abusers of methamphetamines.
Survey pinpoints concerns dental professionals have about treating abusers of methamphetamines.
Crystal meth is a methamphetamine derived from its parent drug amphetamine. Amphetamine was used originally in nasal decongestants and bronchial inhalers. Crystal meth was first seen in South Korea and Taiwan. It came to the market as a legal appetite suppressant and was also used to treat attention-deficit hyperactivity disorder, narcolepsy, and depression. Today, it is a schedule II drug with a high abuse potential and limited medical use. It is available by prescription only and cannot be refilled. It is infrequently prescribed to temporarily address obesity.
Methamphetamine on the street, however, is most often culled up from underground labs, where the drug is cooked up in varying potencies and with differing purities. It usually appears as a white powder called crank, speed, crystal, candy, or tweek, or clear crystals usually called ice or crack. Meth is ingested by swallowing it, snorting it, or injecting it, all of which produce effects almost immediately.
A cheap, reliable, and available addiction
To obtain more information about methamphetamine use, I contacted a local recovery home. I conducted five interviews with men who were former meth addicts. All five men had used for at least 10 years and some closer to 20 years. These ex-addicts are desperately trying to regain control of their lives.
One man states proudly, “I’ve been clean now for 85 days. I’ve tried to stop before but always had a relapse every two weeks or so, but now, I’m on the winning side of a battle.”
Crystal meth tempts users with dramatic bursts of energy, talkativeness, and excitement. After ingesting meth, users immediately feel an intense rush, decreased appetite, decreased fatigue, boosts in alertness and confidence, and feelings of exhilaration or euphoria. Meth users don’t need sleep or food, and they can keep going on and on for hours on end.
The highs are so incredibly high, but the lows are so devastatingly low. Meth energy lasts six to eight hours, then slams the user into an exhausted, weak, drug-craving crash. This only leaves users wanting more. Meth is usually used in a binge/crash pattern. The average binge lasts three days before the user runs out of money or hook-ups and is forced into the painful crash.
Users choose meth because it is more widely available at lower prices than most other illicit drugs. It costs about one-fourth as much as cocaine and its high lasts 12 to 20 times as long. This drug of choice can also be easily manufactured with common household products. Methamphetamines are manufactured in laboratories everywhere. They are found at abandoned farms, country homes, and sometimes in the basements or bathtubs of homes in residential areas. Meth can be produced with readily available inexpensive materials such as over-the-counter cold medicine, fertilizer, battery acid, and hydrogen peroxide - making manufacturing impossible to control.
The telltale signs
Meth abusers can usually be detected by many telltale signs that ruin the abusers’ health. Many users compulsively repeat meaningless tasks for hours, or pick at imaginary bugs on their skin until it bleeds. Methamphetamine causes brain, heart, kidney, and liver damage among other physical effects. It quickly ruins a heavy user’s appearance. Lack of sleep and nutrition, as well as the effects of the toxic chemicals in the drug, ruin the complexion and waste away the body.
The body reacts to crystal meth the same way it reacts to danger. It floods the body with adrenaline, the same hormone that prepares it for emergencies. Adrenaline gives users a super-charge of strength and endurance. Meth gives users the ability to stay awake and do continuous activity with less need for sleep. Although users feel high and full of energy and their bodies keep going, a great deal of damage is being done to the body and brain.
Crystal meth first affects the central nervous system, including the brain. After using meth, a user’s nervous system is shifted into high gear. Neurotransmitters send “emergency alert” messages to the heart, the digestive system, the kidneys, the lungs, and the glands that make the body’s hormones. The eyes’ pupils enlarge, blood vessels constrict, and body temperature rises. Over time, stores of neurotransmitters become depleted, paranoia and anxiety become more frequent, and psychosis develops from too much dopamine, norepinephrine, and lack of sleep. Also, recent research has shown that long-term meth use destroys nerve cells in the brain that regulate dopamine, muscle movement, memory, and decision making. This damage can be widespread and permanent.
Crystal has many other effects on the body. Within the respiratory system, materials used to cut meth can block blood vessels in the lungs, and long-term use can permanently reduce the amount of air the lungs can take in. Within the circulatory system, meth causes the heart to beat faster and harder, veins and arteries to constrict, blood flow to reduce, and blood pressure to increase. The blood clots more readily to stop bleeding because the body thinks it might be hurt. Within the digestive system, meth stops or slows down the movement of the digestive tract. This slows down the breakdown of food and nutrients. Appetite and thirst decrease, causing concern for malnutrition, anorexia, weight loss, cramping, and dehydration.
More clues inside the mouth
Some of the biggest telltale signs of meth users are not so well hidden inside of their mouths. Meth can cause serious problems in a user’s mouth. Meth users are not likely to brush and floss when they are high, and they only go to sleep and wake on average of every three days. Usually, when they are going to sleep they are so depressed they do not brush, so oral home care presents a major risk factor.
Crystal shrinks blood vessels, including the ones in the mouth - not enough blood nourishes the teeth and gums properly. With repeated shrinking, the vessels will not recover, thus causing dental tissue to starve and break down. The end result is tooth decay, gum disease, and bone loss.
Meth causes dry mouth, which leads to many problems. Some of the chemicals used to manufacture methamphetamine are caustic, meaning that they can burn the skin. These harmful chemicals will also come into contact with the soft tissue or mucosal lining of the oral cavity. Without saliva present to protect the oral tissues, severe inflammation, painful mouth sores, and ulcers can develop. Also, continuous friction between the tongue and the inside of the mouth, without saliva acting as a surfactant, can cause skin to become raw and irritated, which can lead to infection.
Without saliva, acids build up, lowering the pH of the mouth and causing the breakdown of the surface of the teeth. Meth users are notorious for trying to treat cottonmouth with lots of sugary soda, which only adds to the problem.
Feedback from dental peers about meth
There are currently no statistics on meth mouth, as the condition has come to be known, because addicts are reluctant to admit their drug use, but there are signs it is on the rise around the country.
In March 2005, I conducted telephone interviews with 150 dental professionals (75 dentists and 75 dental hygienists). They were all asked the same five questions:
- Does your office have a designated place on the medical history form to disclose information about past or current illegal drug use?
- Have you noticed trends or patterns in the way dental caries present in these patients?
- Have you noticed any differences in the use of local anesthesia when treating former or current meth addicts?
- When, if ever, do you consider local anesthesia a contraindication for treating addicts?
- What kind of home-care instructions would you recommend to a current user?
All of the dental offices surveyed have a designated place to disclose information about recent or present drug use; however, not all of the medical history forms specified illegal drug use.
This survey determined that 6.5 out of every 10 dental professionals surveyed noted patterns in the way dental caries presents in patients that use crystal meth. Cavities caused by meth may be different from other cavities. In general, cavities that are left untreated will invade the dentin. Once decay crosses the dentinoenamel junction, the tooth will need a Class II filling or restoration. Invariably, meth users’ cavities will appear large clinically but will not extend past the junction into the dentin. They remain Class I caries. This evidence led to the suggestion that it may not be solely the bacterial factor that is the leading cause of meth cavities. Users who smoke or snort crank allow the very harsh and volatile chemicals to come into direct contact with the outer surface of the teeth. The chemicals can cause breakdown of the enamel by erosion, and this could be the leading cause of meth-induced cavities.
Another important point is that abusers’ teeth often will break completely away at the gum line. The survey’s responses also led to some evidence that it was not mainly due to decay because it had not penetrated deep into the tooth structure. The primary cause may be from the lack of nutrients and blood supply, leaving the teeth brittle and vulnerable. Anxiety caused by the drug prompts users to grind their teeth. Bruxism is very common in meth users; it causes calcium leaching, and clenching of the jaw to the point that the teeth fracture.
All of the dental professionals who participated in the survey agreed that local anesthesia is a topic of concern for meth users. Dental professionals must question their patients to ensure they have not used meth during the 24 hours prior to dental treatment.
The combination of methamphetamines and local anesthetics can be very dangerous, possibly even fatal. If too many other drugs are in the bloodstream, some substances can reach toxic levels since the liver cannot break down an overload of toxic substances. Having an overabundance of drugs in the body can also lead to dangerous drug interactions and stimulant overdose.
An increasing number of users have HIV, AIDS, or hepatitis C, and already have impaired hepathic function that compromises the liver’s ability to metabolize toxins. Chances of heart attack, stroke, or coma increase tremendously.
More circumferential evidence found that 7.8 of every 10 dental professionals surveyed say that it is harder, when performing dental treatment on a current or former crystal abuser, to achieve profound anesthesia. It is common that when profound anesthesia is reached, the duration of action is much shorter, making it difficult to complete restorative procedures. It was hypothesized, by a few dentists, that it has something to do with a user’s drug receptors being faster-acting than normal. The receptors are in a habit of being over stimulated and needing to quickly move chemicals into the bloodstream and to the liver for detoxification and biotransformation. There is not any current research on this topic but it is becoming more of a concern for dental professionals.
Every dental professional has his or her own method of educating patients; however, throughout my survey, there were some common themes. Meth users must be advised to plan for dental care before they get high, brush their teeth daily, floss on a regular basis, check their teeth and gums often, and drink lots of water to keep their mouths moist, especially when they are high in order to decrease the effects of cottonmouth. They should try to stay away from sugary foods and drinks as well. The dental professional needs to assess the meth user’s receptiveness to patient education and should individualize instructions accordingly.
Two (I’ll call them Wells and Thompson) of the five men interviewed at the recovery home agreed to come to Lane Community College to have radiographs and dental hygiene treatment. They graciously granted permission for intraoral photos and to continue the interviews.
According to Wells, seeking dental treatment is an important part of an addict’s recovery. He says, “Before I started doing meth, I didn’t have a cavity in my head.” Now Wells is missing almost half of his teeth, and the ones that remain are a far cry from healthy. He sadly states, “It reminds me a lot of my addiction.” Thompson adds, “Recovery is a delicate process and becomes harder with constant reminders of addiction; my toothless grin is almost taunting, not to mention embarrassing.”
Wells and Thompson present with many missing teeth, and crowns fractured completely away at the gum line, where only root tips remain. They both have severe inflammation, and heavy supragingival and subgingival calculus deposits. Figure 1 is intraoral photos taken on Jan. 5, 2005.
Thompson states that he used meth the most while he was a truck driver. “When I was driving the truck, I didn’t want to stop just to do (snort) a line, so I would steer with my left hand and use my right hand to snort the meth, so I always used my right nostril.” Upon exposing his panorex radiograph, it became clearly visible that significant damage was done to his right nasal passage. It appears much larger in size, as if the lining has been completely eaten away. Figure 2, a panorex, was exposed on Jan. 14, 2005.
Most people would not be pleased with a toothless or partially toothless smile, so we wonder why or how these people would still not seek dental care. The answer, however, is simple. Thompson explains that heavy users are not integrated into mainstream society. They usually only associate with other people who are also heavy users. Their friends and support groups are largely edentulous, or partially edentulous. It is socially acceptable to have this sort of appearance.
In our society, the definition of beauty has changed. It has gone well beyond lips, eyes, eyebrows, and hair, focusing more now on our smiles. These men live in embarrassment of their smiles everyday. It is a taunting reminder of their mistakes and the long journey they have ahead of them. They are all currently saving money to have dentures fabricated as soon as possible. One man states, “It could never be soon enough.”
Carrie Wright, RDH, is a recent graduate who practices in a general practice in Corvallis, Ore. Although her current office does not have any specific outreach programs for meth users, she said, “We still encounter many patients that use meth, due to the prevalence of addiction in the area. My research still continues with anyone willing to participate in interviews.” She can be contacted at firstname.lastname@example.org.