“meth mouth”c1-preview.prosites.com/30459/wy/docs/s... · 4/27/2013 · • heart rate, blood...
TRANSCRIPT
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“METH MOUTH” Oklahoma Dental Association Meeting April 27, 2013 Susan Settle, D.D.S.
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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
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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
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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
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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
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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
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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
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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)
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History Of Methamphetamine • Ephedra: plant used for its stimulant properties for 5,000
years • 1885: ephedrine isolated
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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
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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)
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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)
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History Of Meth • 1959: FDA bans inhalers
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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
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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."
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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
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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
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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
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History • 1990’s: meth can be quickly and easily made in home
labs • Dangerous: process generates toxic residues and is
highly flammable
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OBNDD: Five meth lab disposal containers are located in Tulsa, Oklahoma City, McAlester, Ponca City and Duncan
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Different forms of Meth
Meth can be injected, smoked, snorted, or swallowed
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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
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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
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Meth Mouth
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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?
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Meth Mouth
• Pattern of decay on buccal smooth surfaces & interproximal
• Lack of attention to oral hygiene during bingeing, often for days or weeks
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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
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Rampant Caries
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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”
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Methamphetamine Induced Caries
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Meth Mouth
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Is This Patient Using Meth?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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Faces of Meth
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Questions? Thank you!