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“METH MOUTH” Oklahoma Dental Association Meeting April 27, 2013 Susan Settle, D.D.S.

Recent Oklahoma Headlines •  Judge sentences Oklahoma woman to 18 years in fatal

motor home fire that killed three children • Police find methamphetamine in million dollar home in

Nichols Hills •  Tulsa apartment shooting: 4 women killed midday in home • Boley: Oklahoma court records blame son's meth use in

parents' slayings • Meth raids nab 25; ring moved drug from Mexico, police

say

Mexican Drug Cartels • Are the source of most meth that is smoked (versus

injected from home-derived sources) • Have been directly or indirectly involved in recent state

and federal drug busts •  Elk City, OKC, Midwest City, Norman, Yukon, Mustang, Tulsa,

Weatherford, Anadarko, Chickasha, Lawton, Edmond, Shawnee, Tecumseh, Ardmore, Watonga, Durant, Tishomingo, Thomas, McAlester, Heavener

• Almost all involving the Sinaloa cartel that has spread to all major cities in the U.S. •  Involved in marijuana, heroin and methamphetamine distribution

Possible Dental Outcomes For Persons Using Methamphetamine • A person who has used methamphetamine in the last 24

hours should refrain from receiving dental treatment •  Potential interaction with vasoconstrictors can increase risk of heart

attack or stroke

• Patients who are actively, repeatedly using meth may not be ideal candidates for elective dental treatment •  Restorative treatment may be doomed to failure •  May present with confusion, irritability, panic, paranoia •  May present with attrition due to clenching/grinding

• Meth increases the body’s demand for energy •  Users consume more carbohydrates – sugar and starches, leading

to rampant caries: meth mouth

Evidence That Your Patient May Be Using Meth • History of losing weight • Appearance of xerostomia • Neglect of oral hygiene; increased plaque

•  Appearance of new gingivitis or bone loss

• Appearance of smooth surface decay •  Tremors of the hands • Personality changes • Possible skin lesions (patient feels that insects are

crawling on or under skin) • Complaint of TMJ discomfort; presence of wear facets or

fractures due to clenching and/or grinding

What Is Methamphetamine? • A very powerful central nervous system stimulant of the

amphetamine class used by twenty-six million people worldwide (ten million U.S. estimate)

•  Increases levels of dopamine in the brain •  Also increases serotonin and norepinephrine to a lesser extent •  Dopamine is a “feel good” neurotransmitter •  Responsible for the “rush” initially felt by users •  Tolerance builds to this feeling and dopamine levels decrease with

continued use

• Chronic and/or high-dose methamphetamine use may lead to permanent alteration of the central nervous system

What Is Methamphetamine? • A sympathomimetic drug: mimics what happens during

“fight or flight” reactions •  Heart rate, blood pressure increase •  Respiration rate increases, bronchioles dilate •  Pupils dilate •  Appetite decreases •  Insomnia can occur •  Elevated temperature; increased perspiration •  Increased libido •  Increased alertness and activity, decreased fatigue and drowsiness •  Possibility of developing Parkinson’s Disease

Methamphetamine Is: • A controlled substance – DEA Schedule II drug • Accepted for medical use but has a high potential for

abuse •  The principal drug of concern in our state for DEA/

OBNDD (meth use 42% higher than national average)

History Of Methamphetamine • Ephedra: plant used for its stimulant properties for 5,000

years •  1885: ephedrine isolated

History Of Methamphetamine

• Methamphetamine: structurally is an amphetamine • Amphetamines: adrenergic or sympathomimetic drugs (stimulants – speed)

• Sympathomimetic drugs- think of “fight or flight” reactions: dilated pupils, rapid heart beat, increased BP

• Amphetamine: first synthesized in Germany from ephedrine, 1887

• Methamphetamine: more potent than amphetamine, first synthesized in Japan, 1919

History Of Methamphetamine • Amphetamines were drugs looking for a disease until the 1920’s, when they started to be used for just about everything

•  Their abuse potential was not really known until later

• 1932 over-the-counter Benzedrine (amphetamine) inhaler for the relief of symptoms of breathing disorders (amphetamines are bronchiole dilators)

History Of Use • Amphetamine was aggressively marketed for people with asthma, seasonal allergy sufferers and anyone with a cold

• "Pep pills" were sold over the counter • Benzedrine: amphetamine • Dexedrine: dextroamphetamine • Desoxyn: methamphetamine, the most rapidly acting drug of the group (used to treat ADHD, narcolepsy and exogenous obesity)

History Of Meth •  1959: FDA bans inhalers

History Of Meth •  1960’s: Illegal manufacture and distribution increases

(and abuse potential is being documented) •  1960’s: widespread use as antidepressants and diet pills •  1960’s 1970’s: “speed freaks” appear

•  West coast motorcycle gangs

• Also used as a “study aid” •  1980’s to present: appearance of drug cartels that

produce meth in large quantities outside the U.S. •  2006: National legislation to restrict access to

pseudoephedrine

Dexedrine Brand name for dextroamphetamine. "Many of your patients -- particularly housewives -- are crushed under a load of dull, routine duties that leave them in a state of mental and emotional fatigue...Dexedrine will give them a feeling of energy and well-being, renewing their interest in life and living."

Oklahoma •  April, 2004: first state to make hard tablet

pseudoephedrine (a meth precursor) a Schedule V controlled substance

• Pseudoephedrine (Sudafed nasal decongestant) must be purchased in the pharmacy

• April, 2009: DOB in addition to signature and ID needed to purchase

Oklahoma: Pseudoephedrine Restrictions

• July, 2012: • Pharmacist must use a real-time tracking system for sales • Purchasing cannot exceed:

•  3.6 g/day limit •  7.2 gram limit for 30 days •  60 g limit for 12 months

History Of Use • Currently used to treat narcolepsy, ADHD and obesity •  To treat low blood pressure • Asthma • Appetite suppressant • Antidepressant • Given to soldiers in WWI to increase energy (“pep pills”)

and decrease appetite • Hyperactivity •  Impotence • Night-blindness

History •  1990’s: meth can be quickly and easily made in home

labs • Dangerous: process generates toxic residues and is

highly flammable

OBNDD: Five meth lab disposal containers are located in Tulsa, Oklahoma City, McAlester, Ponca City and Duncan

Different forms of Meth

Meth can be injected, smoked, snorted, or swallowed

Forms of Administration • Listed in order of rapidity of uptake:

•  IV, smoking, snorting, ingestion •  Ingestion is usually used by recreational users and for medicinal purposes

•  Addicts will use IV or smoke meth

Use Patterns

l Many will use meth in a “binge & crash” pattern l Euphoric effects start wearing off quickly, so more drug is

used to reproduce the high l May go on for days or weeks l Sleep may be negligible, contributing to mental problems

l Results in “tweaking” behavior

l Users may take up to 15 g/day l Meth is typically sold in 1/4 gram, one gram, and 1/8 ounce doses

Meth  Mouth  

Meth Mouth • Oral effects: • Dry Mouth •  Frequent drinking of

high sugar liquids- Mountain Dew, Dr. Pepper, sports drinks

• Rampant caries • Poor oral hygiene • Grinding and clenching

of teeth • Acidic (corrosive)

nature of drug (?) or dry mouth?

Meth Mouth

• Pattern of decay on buccal smooth surfaces & interproximal

• Lack of attention to oral hygiene during bingeing, often for days or weeks

A  Typical  Scenario  

• 20-­‐30  y.o.  female  • Drinks  a  lot  of  soda  • Denies  history  of  illicit  drug  use  

• Steady  employment  • Went  to  the  dentist  out  of  concern  for  appearance,  not  due  to  pain      

Rampant  Caries  

Patients  Often  Deny  Meth  Use  

•  27-­‐year-­‐old  male  • When  questioned  about  meth  use,  denied,  but  said  his  brother  used  meth  

• Meth  users  will  usually  either  tell  you,  or  “lie  until  they  die”  

Methamphetamine  Induced  Caries  

Meth  Mouth  

Is This Patient Using Meth?

Research Indicates There Is Not An Identifiable Pattern Of Dental Disease Specific To Methamphetamine Use

• Factors include: • Behaviors coinciding with drug use

• Increased sugar consumption • Oral hygiene neglect • Poor nutrition • Smoking effects

Research Indicates There Is Not An Identifiable Pattern Of Dental Disease Specific To Methamphetamine Use • Other factors include:

• Drug side effects • Xerostomia • Appetite suppression • Bruxism • Dehydration

• Social and environmental conditions • Socioeconomic status • Childhood access to dental care

Xerostomia And Meth • Xerostomia is probably the most important factor in

development of “meth mouth” • Stimulatory effect of the drug causes reduction in amount

of salivary flow and decreased flow rate • Dehydration (due to increased metabolic rate) may also

play a role • Results in increased caries risk, enamel erosion and

periodontal disease • Saliva changes in quality and quantity; buffering effects

are altered, leading to an increase in oral bacteria

Pharmacology Of Xerostomia And Meth • Methamphetamine is a sympathomimetic drug that acts

on alpha adrenergic receptors of salivary gland vasculature •  Produces vasoconstriction and reduces salivary flow

•  The pH change in saliva may not be a major factor as pH must drop below 5.5 for enamel dissolution •  Recent studies indicate the pH falls to about 6.4 during meth use

• CNS effects increase the metabolic rate leading to physical overactivity and hyperthermia •  Leads to excessive perspiration and also to a sensation of oral

dryness

Xerostomia And Meth • The stimulatory effect of the drug causes

vasoconstriction and reduction in quantity of salivary flow

• Also may decrease flow rate • Dehydration resulting from increased metabolic rate (a

CNS effect) may also be a factor • Results in increased risk for caries, enamel erosion and

periodontal disease • Saliva changes in quality and quantity – buffering

effects are altered and leads to an increase in oral bacteria

Xerostomia: Treatment • Sugarless xylitol mints or gum to stimulate flow • Water at all times • Salivary substitutes • Prescription drugs (cholinergic agonists to stimulate flow)

•  Pilocarpine (Salagen): 5 mg, three times/day •  Cevimiline (Evoxac): 30 mg, three times/day •  Adverse reactions of sweating, hot flashes, diarrhea often result in

poor compliance with these drugs

Practice Considerations • Dental professionals should be trained to recognize

symptoms that may indicate use of methamphetamine • Routinely and non-judgmentally ask patients about

possible substance abuse • Do not confront a patient who may be a “tweaker”

•  Dangerous time when user has not slept in days and becomes irritable and paranoid

• Refer patients for medical evaluation and/or treatment

Some Assumptions Being Challenged • Vasoconstriction:

•  Chronic vasoconstriction of the arteries supplying the upper front teeth from frequent (snorting) use leads to decreased arterial blood flow to this area

•  Vasoconstrictive agents in arteries cause significant decrease in blood flow to the maxillary anterior teeth & pulp

• Snorting methamphetamine results in greater wear of anterior maxillary teeth

• Acidic nature of caustic ingredients used in methamphetamine contributes to enamel erosion, dental caries, damage to restorations

Other Possible Factors

•  Increased acid in the mouth from regurgitation of stomach contents, bulimia, or vomiting contribute to increased cavities & erosion problems

• Smoking (tobacco)- chronic heavy smoking leads to decreased oxygen delivery to tissues

Meth Mouth

• Pattern of decay on “cheek-side” smooth surfaces & in-between teeth

• Lack of attention to oral hygiene during bingeing, often for days or weeks

Meth Mouth • In between bingeing, the person may “clean up” orally, thus accounting for what sometimes appears to be a longer caries cycle than early childhood caries or radiation caries

•  Progression pattern is similar to that seen with Sjögren’s syndrome

• Many people go to the dentist when they are not bingeing • Go not for pain relief but from embarrassment, or

they are in treatment for addiction

Importance In Dental Treatment

•  Irregular heartbeat, heart attack and stroke are primary concerns for patients using methamphetamine

• Do not use local anesthetics with vasoconstrictors during the immediate period (up to 24 hours) following use of meth

• Vasoconstrictor use can lead to hypertensive crisis, cerebrovascular accident (stroke), or myocardial infarction (MI or heart attack)

• Deaths have been recorded in medical, but not in dental settings, but it is a possibility

Management: Meth Mouth

• Evaluation of the patient - identify the problem: can the oral problems be caused by meth use? •  If so, discuss professional assistance for the substance abuse if the patient is receptive

• Consultation - referral for medical consult to local physician, or substance abuse clinic if patient is receptive

Management: Meth Mouth

• Documentation - Document exam results and questions you asked the patient

• Educate - Inform the patient about the profoundly deleterious effects of meth on oral health

• Periodic Exams- Establish recall visits to ensure the maintenance of oral health after definitive treatment

• Collaboration with pharmacists- call in any prescriptions – don’t give out DEA number to patient with written prescription

Treatment Considerations • Most important for success: the patient must stop using

the drug • No elective treatment during active drug use

•  Prophylaxis/periodontal appointments may be beneficial during this time

•  Increase water consumption • Consider chlorhexidine use • No local anesthetic with vasoconstrictor for at least 24

hours following use • Consider using: Mepivacaine 3% (Polocaine or

Carbocaine) • Citanest 4% (prilocaine)

Treatment Considerations • Educate/reinforce oral hygiene importance • Encourage water use instead of high-sugar drinks like

Mountain Dew or Dr. Pepper • Neutral sodium fluoride supplementation • Use sugarless gum to stimulate saliva flow • Avoid caffeine and alcoholic beverages (contribute to

dehydration) • Caution when administering local anesthetics,

anxiolytics, nitrous oxide • Patient in recovery: no restrictions • Meth users may be using sedative drugs to sleep

•  Use caution if prescribing other CNS depressants such as opioid analgesics

Dental Treatment Considerations • Encourage water use instead of high-sugar drinks •  Fluoride supplement • Sugarless gum to increase saliva flow • Avoid caffeine and alcoholic beverages (contribute to

dehydration) • Avoid opioid pain pills • Caution when administering local anesthetics, sedatives,

nitrous oxide • Patient in recovery: no restrictions

Faces of Meth

Questions? Thank you!