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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