Download meth mouth 2015 - NC Dental Hygiene Academy of Advanced Studies

REALITY:
Users do seek care!!! But….
Meth Mouth
Oral Manifestation of an
Addiction
Debbye Krueger, RDH, BS,
FAADH
Methamphetamine
MYTHBUSTERS
Myth: Drug users look strange
REALITY:
Some are your
everyday patients!
Some are high school
students
Some may be your
own children
You never know for
sure unless you ask!
www.aadh.org
Professional growth through
leadership, mentorship and
fellowship
SUNSTAR
A HISTORY OF EXCELLENCE
Dr. John Oscar Butler, a periodontist from Chicago
founded the company in 1923
In 1988 the J.O. Butler company became global by
partnering with Sunstar, Inc.
New corporate identity
Little or no follow-up
Poor hygiene
Poor prognosis
Myth: I don’t see meth patients
in my dental office
Something every dental
professional needs to know
Vasoconstriction
Reduced blood supply causes tissues to break
down
With repeated shrinking, the blood vessels don’t
recover and tissues die
This affects every aspect of health
3 years 5 months after starting
meth
REALITY:
This 31 yr old is in a
dental office!
Cervical decay
Poor hygiene
Argumentative
Short temper
Impatient
1
What is Methamphetamine?
1991-1997
Psychostimulant
Stimulates the sympathetic and/or central
nervous system
Legally prescribed for various disorders
Narcolepsy
ADD/ADHD
Obesity
How does it work?
Prevalence
Triggers dopamine,
norepinephrine and
seratonin
Causes euphoria and
excitement
May lead to obsessive
behaviors
When the dopamine level
reaches a certain point it
becomes neurotoxic
Withdrawal includes
2005
The National Survey of Drug Use and
Health
10.4 million people >12 yrs. had used
1.3 million people <12 yrs. had used
CDC report:
9.8% of high school students had used
Sleeping excessively
Depression and anxiety
Excessive eating
Drug craving
Meth in Pills
Methamphetamine Prevalence of Abuse
Monitoring the Future Survey, 2009
Yaba
meth in the form of small, brightly colored pills that are often
flavored with grape, orange, or vanilla
Yaba is Thai for “crazy medicine”
8th
Grade
10th
Grade
12th
Grade
Lifetime**
1.6%
2.8%
2.4%
Past Year
1.0
1.6
1.2
Past Month
0.5
0.6
0.5
taken orally or crushed to be snorted or otherwise ingested
The pills can fit into the end of a straw
Causes Hep C from Sharing Straws
Usually reddish-orange or green with a logo
WY is a common logo.
10 top reasons MA is
popular
• Cheap to produce ($600 of material=$2,000 MA)
• High lasts on average twelve hours (cocaine
averaging one hour in comparison)
• It’s easy to make.
• Materials used to manufacture meth are readily
available
• It can be smoked, snorted, melted and injected,
taken orally, placed rectally, optically or vaginally
http://www.streetdrugs.org/methamphetamine2.htm
2
Differences Between Methamphetamine and Cocaine
(Psychostimulants)
Methamphetamine
Effective central nervous system (CNS) stimulant
euphoria
strength
endurance
Highly addictive, very low recovery rate
User’s mental health is altered so they are not aware of
the effects
Keeps people awake and alert
Because they can
Hydrochloric acid
Ether
Lye
Chloroform
Freon
Drano
Lighter fluid
Lantern fuel
Rock salt
Dry ice
Battery acid
Propane
Cocaine
Man-made
Plant-derived
Smoking produces a high that
lasts 8-24 hours
Smoking produces a high that
lasts 20-30 minutes
50% of the drug is removed
from the body in 12 hours
50% of the drug is removed
from the body within 1 hour
Limited medical use
Used as a local anesthetic in
some surgical procedures
Accessible
Relatively inexpensive
An Incredible Hook
95% become hooked for life on the first try!
Once you are hooked, you may only have 7
years to live.
Life impact:
Loss of interest in friends, family, and every aspect of
your life.
Existence becomes a search for the next high.
The making of Meth…
Red phosphorus
Pseudoephedrine/ephedrine
Found in OTC cold medicines
Blue iodine
RED, WHITE AND BLUE Process
“The alarming growth of
methamphetamine use over the
last 10 years and, in part, its
popularity can be explained by the
drug’s wide availability, ease of
production, low cost, and highly
addictive nature.”
Charles Curie, M.A., A.C.S.W.
(SAMHSA)
April 2005
Manufacture of
Methamphetamine
Most common is a quick cook process requiring only
a few hours.
Simple chemical recipes available online
Highly explosive chemical reactions involved.
Process creates toxic fumes and leaves highly toxic
residues.
Clean up of meth labs is the #1 use of toxic
superfund clean-up dollars in California, 2nd highest
in Oregon.
Common ingredients in Methamphetamine production
Product
Available From
Side effects
A corrosive acid with vapors that are irritating to the respiratory system, eyes,
and skin. If ingested, causes severe internal irritation and damage that may
cause death.
Hydrioic acid
Pool supply
Tincture of iodine
Feed store
Give off vapor that is irritating to respiratory system and eyes. Solid form irritates
the eyes and may burn skin. If ingested, cause severe internal damage.
Paint store
Extremely flammable, posing a fire risk in and around the laboratory. Inhalation
or ingestion of these solvents causes severe gastric irritation, narcosis, or coma.
Aceton/Ethyl alcohol
Strike pad on match
book
May explode as a result of contact or friction. Vapor from ignited phosphorus
severely irritates the nose, throat, lungs, and eyes.
Psuedonepherine
Pharmacy
Ingestion of doses greater than 240 mg causes hypertension, arrhythmia,
anxiety, dizziness, and vomiting. Ingestion of doses greater than 600 mg can
lead to renal failure and seizures
Phenylpropanola-mine
Pharmacy
Ingestion of doses greater than 75 mg causes
hypertension, arrhythmia, anxiety, and dizziness. Quantities greater than 300 mg
can lead to renal failure, seizures, stroke, respiratory failure and death.
Lithium
Batteries
Extremely caustic to all body tissues. Reacts violently with water and poses a fire
or explosion hazard.
Anhydrous ammonia
Fertilizer
A colorless gas with a pungent, suffocating odor. Inhalation causes edema of the
intestinal tract and asphyxia. Contact with vapors damages eyes and mucous
membranes
Automotive
Inhalation can cause sudden cardiac arrest or severe lung damage. It is corrosive
if ingested.
Red phosphorus
Freon
3
Typical Dosage Amounts
The high from a “quarter” of meth will
typically last between 6-8 hours (depending
on tolerance & quality).
Meth is considered “the poor man’s cocaine”
because it is more cost effective than
cocaine (it provides a longer high for less
money).
Use may run up to $3,000 a day
Georgia
Third in the country in teen meth use
Why so low on the seizures when
emergency room numbers are
increasing?
Hundreds
25
23
21
19
17
15
13
11
9
7
5
3
1
-1
MI KS MN IN PA IA MO NE IL KY OH NY WI
Seizures
Meth Lab Incidents
METH MOUTH
The changing face of
dental disease
4
Meth Mouth
Xerostomia The first sign of meth
use
Smoking
Meth causes extensive tooth decay.
Often the teeth cannot be saved and must be removed.
It is believed this is due to the acidic nature of the drug,
vasocontriction and severe dry mouth.
While users are high, they crave sweetened foods and
often grind their teeth.
Sympathetic nervous system affected
Unstimulated salivary flow reduced
Increased protein level in saliva exacerbates dry feeling
Hyperactivity results in less eating/drinking
Patients experience generalized dehydration
Increase potential for consuming sugary, high
carbohydrate soft-drinks
http://www.ada.org/public/topics/methmouth.asp
ORAL
The dental professional is
usually the front-line
healthcare worker to detect
methamphetamine abuse…¹
Slowest rate of absorption
Taken in pill form or drunk as in “Biker’s coffee.”
Must pass through the mouth enzymes and
stomach acids
Absorbed through the small intestine
Lag time: 20-30 minutes
INJECTION
Very fast absorption
Injection methods
– intravenous (“slamming” within the vein walls)
– intramuscular (“muscling” - not done with meth)
– subcutaneous (“skin popping” - not done with meth)
Lag time: varies according to method. Because meth is injected
intravenously, lag time is between 10 - 20 seconds
Problems:
- HIV, Hepatitis B, Hepatitis C, endocarditis,
abscesses, cotton fever, blood poisoning, etc.
INTRANASAL (Snorting)
Slower rate of absorption
Powder snorted through the nose
Absorbed by mucous membrane in nasal passages
Lag time: 3 to 5 minutes
Problems:
– Damages nasal membranes
– Risk hepatitis C through shared “straws”
ANAL (Booty Bumping)
Water + meth solution is squirted into the anus or
vagina with a “de-needled” syringe
Absorbed fairly fast through blood vessels in anal
tissue
Lag time: 3 to 5 minutes
Problems
- Repeated booty-bumping can severely
damage tissue in anal or vaginal cavity
- Popular belief that “it’s safer than
injecting.”
5
Optically
We do not know the results yet, new trend, was used in
the 60’s
CRAVINGS
High carbohydrate (non-diet) soft drinks
Mountain Dew (42 g sugar/12 oz.)
17 young adults admitted in one night
Saliva loses buffering effect
Decay on facial and cervical surfaces of all teeth
Eventually decay entire clinical crown
Xerostomia
Sympathetic nervous system affected
Unstimulated salivary flow reduced
Increased protein level in saliva exacerbates dry
feeling
Hyperactivity results in less eating/drinking
Patients experience generalized dehydration
Increase potential for consuming sugary, high
carbohydrate soft-drinks
Possible Short-Term Effects:
Increased attention and decreased fatigue
Increased activity and wakefulness
Decreased appetite
Euphoria and rush
Rapid / irregular heartbeat
Hyperthermia
Possible Long-Term Effects
Oral Implications
What you may experience in the
dental operatory.
Oral signs of MA use
Angular Cheilitis
Addiction
Psychosis, including:
Paranoia, hallucinations and repetitive motor
activity
Changes in brain structure and function
Memory loss
Aggressive or violent behavior
Mood disturbances
Severe dental problems
Weight loss
Physical and social signs of
MA use
Malnourished appearance
Glossitis and alligatoring
Abnormal vital signs
Candidia
Pale complexion, red eyes
Mucosal ulceration
Disheveled appearance
Xerostomia
Irritability or euphoria
Facial pain, Trismus, and myofacial pain resulting
in sever occlusal wear
Nervousness, compulsive behavior, picking of skin
Rapidly progressive periodontitis
Fast aging of patient and sagging of skin
Rampant caries often starting on the buccal
smooth surfaces of posterior and the
interproximal surfaces of anterior teeth
Sweaty, clammy, skin
The teeth tend to die from the inside out
because of vasoconstriction.
They sheer off at the gum line from grinding.
Dr. James Hill, Soladad Prison
http://www.ada.org
6
Caries continued…
Precautions
Oral hygiene is sporadic in meth abusers
Physician clearance prior to any
anesthesia or nitrous oxide
Binge – limited or no oral care
When not using – oral care improved
Have a network of physicians that you can
work closely with
Explains slow progression of caries
Meth can cause serious cardiac and liver
problems
Acidic nature of meth ingredients
Smoking (xerostomia)
What can you do?
Treatment Options
Comprehensive oral examination
dental and medical history.
Express concern Non-judgmental questions
-Something does not make sense in your mouth. Any possibility
you are using recreational drugs?
Referral
physician, clinic or substance abuse rehabilitation facility
be familiar with protocol to educate patient
Preventive measures such as topical fluorides.
Encourage drinking water rather than sugar-containing
carbonated beverages.
Use caution with
local anesthetics, sedatives
general anesthesia
nitrous oxide
prescription narcotics
Educate your patients about the risks
Bruxism
Extensive grinding of teeth
Causes wearing of occlusal surface
Can contribute to periodontal disease
Contributes to recession (abfraction)
TMJ disorders (clenching)
Facial muscle pain
•
•
•
•
•
•
•
Systemic saliva enhancers
Sugarless gum
Fluoride (gels, foams and varnish)
APF fluorides should be avoided
Neutral NaFl will stabilize salivary pH
Take home Neutral NaFl
Encourage drinking water instead of sugary softdrinks
MI paste
Xylitol
Local Anesthetic
Question patients about meth use 24
hours prior to treatment
Blood Panel
Meth and local anesthesia can be
extremely dangerous – even fatal
Liver toxicity
Stimulant overdose potential
Eliminate the bioburden as
much as possible
7
Xylitol
GUM PerioBalance
Options for patients who won’t
floss…
Indications
A recent study has shown that
GUM® interdental cleaners matched
the plaque and gingivitis reduction
of Glide® floss.
A daily dental probiotic mint flavored lozenge
Clinical results have shown positive changes
in gum health in 28 days
Promotes healthy teeth and gums, reduces
plaque and fights bad breath
Contraindications
No known contraindications
Interdental Gingivitis and Plaque Reduction by Four Interdental Products; J
Clin Dent 17:79-38, 2006
Plaque Levels
Avoid Alcohol!
3
Pre-procedural rinse
GUM Alcohol-Free
Chlorhexidine Gluconate
Have patients brush
with an
extra-soft toothbrush
(only available through
Sunstar Americas)
1
0
PerioShield™ Oral Health Rinse
Baseline
Plaque
Final Before
Product Use
Final After
Product Use
2
Flossers
Glide
GoSoft-Picks
Betweens
Lingual Gingivitis
Fluoride Varnish
Active ingredient (delmopinol
0.2%) creates an invisible
barrier and inhibits plaque
formation
Clinically proven to help
reduce plaque buildup and
bleeding on probing up to
36%
Less chair time
Less patient discomfort
Greater acceptability
Especially pre-school aged children
5% NaF (22,600 ppm) fluoride ion
APF 12,300 ppm fluoride ion
NaF 9,050 ppm fluoride ion
Holds fluoride on teeth for an extended period of time
Clinically effective on permanent teeth
Gingivitis Index (GI)
2
Helps prevent and treat
gingivitis that could lead to
advanced stages of
periodontal disease
1.6
1.2
Baseline
0.8
Final
0.4
0
Flossers
Glide Floss
GoBetweens
Soft-Picks
66
8
Buccal Gingivitis
HPV Collection Supplies
Gingivitis Index (GI)
2
The Identafi’s patented 405nm wavelength technology is designed to
identify suspect abnormalities indistinguishable from the naked
eye.
1.6
1.2
Baseline
0.8
Final
“The best discrimination between neoplastic and non-neoplastic areas
was obtained at 405 nm excitation; normal tissue could be
discriminated from dysplasia and invasive cancer with a 95.9%
sensitivity and 96.2% specificity in the training set and with a
100% sensitivity and 91.4% specificity in the validation set.
Disease probability maps”
0.4
0
The Ideal Wavelength for Lesion
Discrimination
*Roblyer et al. CPR [May 2009] – 405 nm autofluorescence optimal
for perception
Flossers
Glide Floss
Go
Betweens
Soft-Picks
Soft-Picks™
Soft, flexible bristles slide
between teeth
Stimulates gums
Tapered design fits between
small spaces
Convenient travel case for onthe-go use
StarDental Identafi
Oral Cancer Screening
System
Natural Fluorophores are present in the oral mucosa that can be used to
non-invasively monitor the development and progression of oral neoplasia.
-
Early Detection Saves
Lives!
Follow with Rincinol
for soft-tissue pain management
What Makes Tissue Fluoresce?
Understanding the Technology
Flavin Adenine Dinucleotide (FAD)
Nicotinamide Adenine Dinucleotide (NADH)
Collagen cross links
Keratin
Hemoglobin
*All of these endogenous biomarkers
naturally fluoresce at a healthy state.
New Website
www.identafi.net
Fluorescence - the emission of light by a substance
that has absorbed light of a different wavelength.
In abnormal tissue pathology, the light emitted is far less
than original (incidence) light source.
As much as 1,000 times weaker than the illumination light
Violet wavelength on the Identafi (405nm)
Reflectance – Immediate bounce back of omitted
light without altering the wavelength or intensity.
Primarily the green amber to identify abnormalities
9
You can make the difference!
Know the signs of use
Have a physician/rehabilitation referral system
Have the necessary equipment to serve this culture
Care enough to ask
THANK YOU!
Resources
DentistryToday.com
Goodchild, J., Donaldson, M., Mangini, D., “Methamphetamine Abuse and the Impact on Dental
Health”, Dentistry Today, May, 2007.
Wikipedia.com
http://en.wikipedia.org/wiki/Methamphetamine; 14:26, 29 November 2007.
Anti-meth.org
http://www.anti-meth.org/brainbody.html
About.com
www.dentistry.about.com/.../07/meth-mouth-video.htm
American Dental Asssocation
www.ada.org
American Academy of Pediatric Dentistry (AAPD): Council on Clinical Affairs
http://www.aapd.org/media/Policies_Guidelines/P_Xylitol.pdf
Streetdrugs.org
National Institute on Drug Abuse
http://www.drugabuse.gov/PDF/RRMetham.pdf
Woman Dentist Journal
Wright, C; “Meth Users”, Woman Dentist Journal, October, 2006
10