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Evaluation of methamphetamine-associated socioeconomic status and addictive behaviors, and their impact on oral health
Addictive Behaviors 50 (2015) 182–187
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Addictive Behaviors
Evaluation of methamphetamine-associated socioeconomic status and addictive behaviors, and their impact on oral health Niklas Rommel a,⁎, Nils H. Rohleder a, Stefan Wagenpfeil b, Roland Haertel-Petri c, Marco R. Kesting a a b c
Department of Oral and Maxillofacial Surgery, Munich University of Technology, Ismaninger Str. 22, D-81675 Munich, Germany Institute for Medical Biometry, Epidemiology and Medical Informatics, University of Saarland at Homburg/Saar, Kirrberger Straße 100, D-66424 Homburg/Saar, Germany Department of Addiction Medicine, Hospital for Psychiatry, Psychotherapy, Psychosomatic Medicine, and Neurology, Nordring 2, D-954, 44 Bayreuth, Germany
H I G H L I G H T S • • • •
MA abuse is connected with a higher risk for intraoral health damaging. We found lower socioeconomic status in MA abusers compared with non-abusers. MA abuse is strongly associated with the consumption of other addictive substances. We detected an absence of dental care among chronic MA abusers.
a r t i c l e
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Article history: Received 14 January 2015 Received in revised form 12 April 2015 Accepted 16 June 2015 Available online 26 June 2015 Keywords: Methamphetamine Socioeconomic status Consumption behavior Dental care Oral health
a b s t r a c t Background: Chronic methamphetamine abuse can lead to multiple health hazards. In particular, the substance is associated with devastating effects on oral health including symptoms such as rampant caries, gingiva inflammation, and xerostomia, whereby the term “Meth Mouth” occurs in the current literature. However, “Meth Mouth” pathology is primarily described on the basis of individual cases or has been evaluated without consideration of the mass of potential influencing factors. Therefore, we have conducted a systematic study to investigate the effects of accompanying factors and circumstances on oral health in cases of chronic methamphetamine abuse. Methods: In cooperation with two centers for addiction medicine, we assessed the data of 100 chronic methamphetamine users and 100 matched-pair controls between March 2012 and November 2013. We investigated their socioeconomic status, details of methamphetamine consumption behavior, collateral consumption of sugar beverages, nicotine alcohol, and other addictive substances including cannabis, opioids, other stimulants, and hallucinogens, and dental care. Results: We found considerably greater unstable social circumstances, a high collateral consumption of substances with pathogenic potential for the stomatognathic system, and significantly poorer dental care in the methamphetamine-user group. Conclusions: Various factors have to be considered with regard to methamphetamine use and its influence on oral health. These factors can trigger potential damage by the drug methamphetamine possibly leading to the symptoms of “Meth Mouth”, and should be considered in prevention and therapy strategies. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction 1.1. The prevalence of the substance methamphetamine The highly-addictive substance methamphetamine is a widespread and serious problem in many countries (Turkyilmaz, 2010). Currently, the prevalence of methamphetamine abuse is estimated at 10 million
⁎ Corresponding author. Tel.: +49 4140 9744; fax: +49 89 4140 2934. E-mail address: [email protected] (N. Rommel).
http://dx.doi.org/10.1016/j.addbeh.2015.06.040 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
people in the United States and 35 million people worldwide (Talloczy et al., 2008). Methamphetamine is illegally traded and widely abused under the scene name “crystal” or “crystal methamphetamine”. Particularly in Europe, the abuse of crystal methamphetamine is rapidly spreading. The police seized 3198.41 g crystal methamphetamine in German border areas to the Czech Republic within the year 2012; this represents an increase of almost 200% in a two-year comparison with 2010 (Police Crime Statistics for Upper Franconia, 2013). Furthermore, in the UK, the abuse of methamphetamine is currently on a large rise in London's Gay Scene and, consequently, puts men at a higher risk of infections (Kirby & Thornber-Dunwell, 2013).
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1.2. Consequences of chronic methamphetamine abuse The chronic use of methamphetamine involves a wide range of potential health hazards including massive weight loss, chronic skin irritations, cardiovascular diseases, structural brain damage, paranoia, or depression (Hamamoto & Rhodus, 2009). Recently, however, the severe consequences of chronic methamphetamine abuse has been described and, in particular, those on the stomatognathic system, which consists of the mouth, teeth, intraoral tissue, and jaws (Curtis, 2006; Donaldson & Goodchild, 2006; Hamamoto & Rhodus, 2009). The term “Meth Mouth” first appeared in the professional literature in 2005 based on findings in the United States (Rhodus & Little, 2005). From that moment to the present date, many authors have drawn attention to the probability of “Meth Mouth” occurrence after chronic methamphetamine abuse (Ravenel et al., 2012; Shaner, Kimmes, Saini, & Edwards, 2006; Turkyilmaz, 2010) including symptoms of rampant caries (Hamamoto & Rhodus, 2009) and extensive gingiva inflammation and parodontitis (Rhodus & Little, 2008; Tipton, Legan, & Dabbous, 2010). These symptoms lead to further health consequences if they are not treated timely and adequately. Progressive caries and oral tissue inflammation can result in massive pain and in complete tooth loss, both of which will influence nutrition behavior significantly. Especially in cases of chronic methamphetamine abuse, this is alarming. Sympathomimetic effects of the drug cause appetite suppression, sleep deprivation, and sensations of intense energy that lead to weight loss (Padilla & Ritter, 2008; Vearrier, Greenberg, Miller, Okaneku, & Haggerty, 2012). In combination with the severe consequences on oral health described above, weight loss will be triggered significantly with life-threatening potential. Furthermore, chronic and progressive caries lesions and inflammation of the oral tissue can spread into other regions of the body and result in dangerous infections such as endocarditis (Verhaaren et al., 1989) or osteomyelitis of the jaws (Ramesh & Ganguly, 2011). At the very least, severe oral conditions are often associated with prejudice and make the social rehabilitation process more difficult for the ex-abuser.
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Therefore, the aim of the study has been to evaluate these various possible influencing factors on oral health in cases of chronic methamphetamine abuse. First, the social status of a typical methamphetamine should be considered. Second, the addictive behavior with respect to the substance methamphetamine, high-sugar beverages, other addictive substances, nicotine, and alcohol should be investigated. Third, the dental care of a typical methamphetamine abuser should be screened. Subsequently, an evaluation should be made as to whether these factors contribute to the “Meth Mouth” phenomenon. To gain an indication of whether a “Meth Mouth” syndrome even exists, we have questioned methamphetamine abusers about oral conspicuities from start of their methamphetamine abuse and requested that abusers should asses their current oral health status. The “Meth Mouth” has primarily been evaluated on the basis of individual case reports, with a lack of conclusive relationships being shown between chronic methamphetamine abuse and oral diseases. Systematic study designs in this field are rare, not least because of the difficult access to a large number of methamphetamine abusers. We have established a collaboration between specialty institutions for addiction medicine and oral medicine in order to conduct a systematic and extensive questionnaire and patient interview including a sufficient number of methamphetamine participants. Furthermore, for optimal comparability of data, we have recruited a matched-pair control participant for each methamphetamine abuser and carried out the complete data analysis in cooperation with a university statistical institute. 2. Methods The study collaboration consisted of the two specialty clinics for addiction medicine in Bayreuth, Germany and Hochstadt/Main, Germany, the Department of Oral and Maxillofacial Surgery of the Munich University of Technology, Germany and the Institute for Medical Biometry, Epidemiology and Medical Informatics of the University of Saarland, Germany. 2.1. Participants
1.3. Potential causes of the “Meth Mouth” phenomenon Various hypotheses for the “Meth Mouth” phenomenon and its symptoms have been suggested. The pharmacologic effects of the drug seem to be one explanation. Methamphetamine blocks the re-uptake of norepinephrine and dopamine and subsequently stimulates the sympathetic nervous system (Donaldson & Goodchild, 2006; Hamamoto & Rhodus, 2009). With regard to the oral region, the consequences are dry mouth (Donaldson & Goodchild, 2006) or extensive grinding of the teeth (Curtis, 2006). Dry mouth is associated with the loss of important protective properties of saliva such as the neutralization of plaque-induced acids and the remineralization of dental enamel, and therefore, dry mouth substantially increases the risk of caries (Fox, 2008). A massive decline of saliva production is considered to play a crucial role in methamphetamine-associated tooth decay (Shaner et al., 2006). In this context, the intake of high-sugar beverages is also considered to be responsible for the excessive tooth wear in methamphetamine abusers (Rhodus & Little, 2005). However, no systematic study designs exist determining whether methamphetamine abusers drink more high-sugar beverages than non-abusers. Additionally, we do not know whether other potential influencing factors on oral health, such as social status or the co-consumption of nicotine, alcohol, or other addictive substances, contribute to these described oral health hazards in a methamphetamine abuser. A lack of dental care and the nonrecognition of the oral health damage might also play a significant role in “Meth Mouth” and have not as yet been evaluated in cases of chronic methamphetamine abuse. Nevertheless, differences in the pathogenic potential of the substance have been described as being dependent on the individual form of methamphetamine consumed (Rawson, Gonzales, Marinelli-Casey, & Ang, 2007).
In order to attain sufficient statistical power and to be able to present data directly in percent, 200 participants consisting of 100 methamphetamine abusers and 100 matched-pair non-users were selected and examined between March 2012 and November 2013. The selection and data acquisition of the methamphetamine abusers took place at the addiction clinics, with the individuals in separate rooms in a quiet atmosphere. First, the executive psychotherapist in each addiction clinic checked the eligibility criteria for this study for the methamphetamine group in a short patient interview. The criteria included constant methamphetamine abuse of 1 g/week for more than a minimum period of 12 months without any withdrawal periods. Additionally, a potential participant had to have reached the 18th year of age, and each methamphetamine abuser was informed that study participation would be absolutely voluntary. If a methamphetamine abuser did not fulfill the eligibility criteria or did not consent to study participation, then he or she was selected out by the executive psychotherapist. All methamphetamine abusers who fulfilled all eligibility criteria and gave written consent to study participation received a detailed questionnaire including three different sections (see 2.2. Data collection); this questionnaire was filled out by the participant. Subsequently, a personal conversation between the methamphetamine abuser, a physician, and a psychotherapist was conducted in order to clarify any existing ambiguities in the questions. The complete data collection including selection, the question and answer section, and the personal conversation took 100 min, on average. The average age of the participants was 29.5 years (SD ± 7.0) with a gender distribution of 17 females and 83 males. For the control group, we defined the matched-pair criteria of gender and age (+/− 1a) and recruited its participants from resident patients at the University Hospital in Munich and from patients of two residential
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Table 1 Data of socioeconomic backgrounds (CM = crystal meth). CM group (n = 100)
Control group (n = 100)
Total (n = 200)
p-Value (statistical test)
Marital status Single Married Remarried Separated Divorced Widowed
% 82 9 1 4 1 3
% 86 14 0 0 0 0
% 84 11.5 0.5 2 0.5 1.5
0.031 (Fisher's exact test)
Current residence Single accommodation Parents/relatives Sharing Homeless Unclear
% 46 32 3 12 7
% 70 19 11 0 0
% 58 25.5 7 6 3.5
b0.001 (Fisher's exact test)
Vocational education University degree Vocational school A-level B-level Secondary modern school No education
% 0 7 5 22 51 15
% 21 4 44 17 14 0
% 10.5 5.5 24.5 19.5 32.5 7.5
b0.001 (Mann–Whitney-U-test)
Job situation Fully employed Part-time work Apprenticeship University student School student Unemployed Unclear
% 17 7 5 0 0 65 6
% 49 9 15 22 2 3 0
% 33 8 10 11 1 34 3
b0.001 (Fisher's exact test)
Subsistence finances Occupation Unemployment benefits Income support Child allowance Relatives/friends Student subsidy Illegal earnings Other
% 18 51 15 4 2 0 3 7
% 66 0 0 9 15 3 0 7
% 42 25.5 7.5 6.5 8.5 1.5 1.5 7
b0.001 (Fisher's exact test)
dental surgeries in Munich. Analog to the methamphetamine group, the eligibility criteria were first checked, followed by the answering of the detailed questionnaire and the personal conversation. Selection and data collection of the control group were performed by two physicians of the University Hospital in Munich. All study participants received an information document including objectives of the study. According to the requirements of the ethics committee, we informed each participant about data use and data protection and obtained his or her written consent to participation in the study.
and reduced salivary flow. Additionally, methamphetamine abusers were asked to indicate whether other methamphetamine abusers in their social environment noticed the symptoms described above.
2.2. Data collection
Table 2 Special data with regard to crystal meth users (n = 100).
In the first section, both groups gave detailed information about their socioeconomic status (SES) including marital status, current residence, vocational education, job situation, and subsistence finances. In the second section, both groups gave detailed information about their consumption of nicotine and alcohol and of high-sugar beverages. The methamphetamine group was additionally asked about the period of the time, frequency, duration, and patterns of individual methamphetamine abuse and the accompanying consumption of other addictive drugs including cannabis, other stimulants, sedatives, or hallucinogens. In the third section, both groups were asked to assess their dental health status and to indicate the date of their last check-up. Methamphetamine abusers, in particular, were requested to specify any noticed conspicuity with regard to their teeth and the mouth and maxilla region directly linked to their methamphetamine consumption, including the symptoms “teeth fragility”, gingiva bleeding, pain in the jaw joints,
2.3. Statistical analysis We used the Mann–Whitney-U-test and Fisher's exact test for testing statistical significance. For each parameter, an adequate
Route of crystal meth administration Intranasal Smoking Intravenous Others
% 91 34 33 4
Consumption of other addictive substances Cannabis/marihuana Stimulants Opioids and sedatives Hallucinogens
% 56 42 22 12
Abnormalities within the stomatognathic system since the beginning of crystal meth use Noticed “teeth fragility” Noticed increased gingiva bleeding Noticed increased pain in the jaw joint Noticed reduced salivary flow Noticed disorders within the oral cavity and jaw joints in other users
% 68 43 46 71 75
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Table 3 Data with regard to consumption of nicotine, alcohol and high-sugar beverages and to dental care. CM group (n = 100)
Control group (n = 100)
Total (n = 200)
p-Value (statistical test)
Smokers Yes No
% 79 21
% 34 66
% 56.5 43.5
b0.001 (Fisher's exact test)
Alcohol consumption Daily Frequently (3–6 times/week) Sometimes (1–2 times/week) Rarely (b3 times/month) No consumption
% 11 10 35 31 13
% 1 3 52 12 32
% 6 6.5 43.5 21.5 22.5
0.019 (Mann–Whitney-U-test)
Consumption of sugar beverages Daily Frequently (3–6 times/week) Sometimes (1–2 times/week) Rarely (b3 times/month) No consumption
% 6 3 33 10 48
% 19 11 22 8 40
% 12.5 7 27.5 21.5 22.5
0.14 (Fisher's exact test)
Self-assessment of dental health Very good Passable In need of improvement Poor Very poor
% 3 16 49 20 12
% 18 43 31 8 0
% 10.5 29.5 40 14 6
b0.001 (Mann–Whitney-U-test)
Date of last professional dental check Within the last 12 month 1 year ago 2 years ago Longer than 2 years ago
% 34 28 14 24
% 66 18 5 11
% 50 23 9.5 17
b0.001 (Fisher's exact test)
Regularity of dental check-ups Regular visits to the dentist
% 31
% 83
% 62
b0.001 (Fisher's exact test)
statistical test was selected. P-values were two-sided and subjected to a significance level of 0.05. We used the software programs SPSS 21.0. (Fa. IBM, Armonk, USA) and Cytel Studio version 10 (Fa. Cytel, Cambridge, USA) for the statistical analysis and Excel 2010 for data transfer and handling. For data regarding professional education, frequency of drinking sugary beverages, and consumption of alcohol, we used the Mann– Whitney U-test comparing medians. For the data of partnerships, current residence, employment, financing of subsistence, consumption of sugary beverages, smoking status, and dates and regularity of dental checks, we used Fisher's exact test comparing relative frequencies. The data that only affected the methamphetamine-abuser-group including frequency, form, and duration of consumption and additional use of other drugs since the beginning of methamphetamine use were assessed purely descriptively without using an inferential procedure. 3. Results We found that chronic methamphetamine usage was associated with considerably more unstable social circumstances than in a sameaged and same-gender person without chronic methamphetamine abuse. In particular, the current employment situation of the methamphetamine abusers was dramatically different, with an unemployment rate of 65% (Table 1). By far the most common route of methamphetamine intake was intranasal administration, which was employed by 91% of all studied methamphetamine abusers. Of all methamphetamine abusers, 76% said that they regularly also used other addictive substances such as cannabis, sedatives, stimulants, or hallucinogens, with cannabis being the most common (56%) as shown in Table 2. Most methamphetamine abusers had noticed multiple abnormalities within the oral cavity and the jaw joints since the start of methamphetamine use (Table 2). A significantly higher percentage of smokers
could be observed within the methamphetamine group (79%) compared with the control group (34%). Furthermore, 21% of all methamphetamine abusers said that they drank alcohol frequently (4–6 times/week) or even daily. However, we found no increased drinking of sugary beverages with regard to chronic methamphetamine abuse. Only 31% of all methamphetamine abusers were under regular dental supervision (control group 83%), although 81% of the methamphetamine abusers rated their individual tooth status as “in need of improvement” or even worse (Table 3). 4. Discussion We found a significant number of accompanying factors with pathogenic potential for oral diseases including unstable socioeconomic conditions with financial constraints, consumption of other addictive toxic substances, and a lack of professional dental care in the case of chronic methamphetamine abuse. Most of the methamphetamine abusers noticed “Meth Mouth”-specific abnormalities within the oral region and the jaw joints from the beginning of methamphetamine consumption. Additionally, methamphetamine abusers rated their tooth status as being significantly worse than a comparable group of non-abusers. These findings are an indication of the damaging effects of chronic methamphetamine abuse and are in agreement with previous presumptions (Donaldson & Goodchild, 2006; Hamamoto & Rhodus, 2009). Research results and empirical data show that dental pain, damaged teeth, and the incidence of caries appear in the event of decreased socioeconomic status and homelessness, and that, in cases of a lack of access to health care, these problems lead to poor oral health (Dye et al., 2007). During our study, each methamphetamine abuser reported more unstable social conditions compared with a test person of the same age; this leads to the inference that the risk of oral diseases is generally increased in the methamphetamine group. Additionally, only 31% of all methamphetamine abusers indicated that they
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underwent regular dental treatment (comparable control group: 83%) and only 34% visited a dentist within the last 12 months (comparable control group: 66%), although most of the methamphetamine abusers noticed a change in their oral cavity related to their chronic methamphetamine abuse and deemed their dental state as an area for improvement or even as being bad. A lack of compliance of the methamphetamine abusers in an acute phase of consumption could be relevant. Excessive fear of the dentist and feelings of shame also have to be considered. However, financial limitations because of an often low socioeconomic status seem to reduce the possibilities of adequate dental therapy for the methamphetamine group. This factor is even present in countries such as Germany in which therapeutic measures are provided, even in cases of weak social status, because of the availability of extensive public health care and health insurance systems and statutory health insurance. Specific supporting concepts for prevention and therapy during methamphetamine abuse are thus necessary. With regard to additional illegal drug consumption, most methamphetamine abusers in this study indicated that they also regularly consumed other addictive drugs such as cannabis, sedatives, stimulants, or hallucinogens. Cannabis consumers exhibit a higher risk for caries and dry mouth (Darling, 2003). Increased gingival lesions and dental erosions are postulated as an effect of cocaine on oral health (Brand, Gonggrijp, & Blanksma, 2008). In the case of ecstasy consumption, dry mouth and increased dental erosions are more prevalent (Brand, Dun, & Nieuw Amerongen, 2008). Long-term opioid consumption can induce dry mouth (Chapman et al., 2010), as can the consumption of tranquilizers such as benzodiazepine (Zaclikevis et al., 2009). In summary, the extensive additional abuse of other substances such as cannabis, other stimulants, opioids, or tranquilizers has to be considered as a relevant trigger factor for caries lesions, oral tissue inflammation, dry mouth, and subsequently substantial tooth decay in methamphetamine abusers. Smokers, who accounted for 79% of all methamphetamine test persons in our study, also have an increased risk of caries. Importantly, the combination of alcohol and nicotine can cause severe intraoral changes in the form of caries, gingival inflammation, and precanceroses (Wickholm, Galanti, Soder, & Gilljam, 2003). The results of this study show that the risk of intraoral diseases is increased solely by the corollary consumption of nicotine and, at times, the excessive corollary consumption of alcohol. Alcohol and nicotine intake might thus also play an important role in the devastating effects of chronic methamphetamine abuse on oral health. High-sugar intake, mainly in the form of high-sugary beverages in order to compensate for the methamphetamine-induced dry mouth, is considered to be the main reason for rapid tooth decay during periods of methamphetamine abuse (Hamamoto & Rhodus, 2009; Padilla & Ritter, 2008). Furthermore, one case report has described a young man with rampant carious lesions, dry mouth, and excessive consumption of high-sugar beverages related to methamphetamine abuse for one year (Shaner et al., 2006). We have found no increased consumption of sugary beverages within the methamphetamine group compared with the control group and, thus, cannot confirm this assumption. However, our participants were only asked about the consumption of sugary beverages and not about their consumption of sugar in detail. Therefore, consumption of other high-sugary substances among methamphetamine abusers cannot be excluded and requires further research. Additionally, individual oral hygiene has to be taken into account in this context. Oral hygiene including correct and regular dental care is an important prevention measure with regard to oral diseases (Hellwig, Klimek, & Attin, 2003). In the case of “Meth Mouth” syndrome, many authors report the strong neglect or complete lack of oral hygiene measures in methamphetamine abusers (Donaldson & Goodchild, 2006; Laslett & Crofts, 2007; Rhodus & Little, 2008). However, these findings are primarily based on case reports with no systematic questionnaire and patient interview, including clinical supervision. A
clinic oral hygiene index combined with a detailed nutrition questionnaire and patient interview might be useful in such studies. Another factor relevant with regard to the implications and consequences of methamphetamine abuse is the method of methamphetamine administration. Methamphetamine can be snorted, smoked, swallowed, dissolved in water, or applied intravenously (IV) or perianally (Schifano, Corkery, & Cuffolo, 2007). Rawson et al. (2007) have examined the consequences of the various methods of methamphetamine administration with regard to psychological and medical impairment and detected IV abuse as being the most highly damaging, closely followed by the smoking of methamphetamine. In comparison with the other two methods of abuse, intranasal abuse displays the least damaging effect (Rawson et al., 2007). With regard to oral diseases and methamphetamine administration, however, different views exist. Shetty et al. (2010) have found the most highly damaging effects to occur with IV abuse, followed by intranasal abuse and smoking, whereas Brown, Morisky, and Silverstein (2013) suggest that the most damaging effects occur after smoking, because of direct oral exposure. In our study, intranasal methamphetamine abuse was dominant followed by smoking and IV abuse. With regard to reported abnormalities within the stomatognathic system and the self-assessment data of methamphetamine abusers in this study, intranasal abuse is also likely to have a high damaging potential. However, we have performed no clinical examination that can confirm this assumption. Nevertheless, in the context of previous observations and from the reports of methamphetamine abusers in this study, we consider that the total dose of methamphetamine is more crucial for oral diseases than any direct effects within the oral cavity. Our findings have to be considered in context with the following study limitations. The data collection took place retrospectively, and so we had to rely on the truthful answers of all study participants; therefore, potential information bias cannot be ruled out. Furthermore, we performed no clinical investigation, and thus, no statement can be made about the clinical consequences of chronic methamphetamine abuse described in previous studies. Our findings with respect to oral abnormalities in methamphetamine abusers and the data concerning the self-assessment of oral health are an indication for specific oral health damage but are not sufficiently conclusive. We recommend a systematic longitudinal study including a detailed clinical examination combined with extensive questionnaire and patient interview with regard to all potential influencing factors in order to improve knowledge of the effects of this drug. In conclusion, many accompanying risk factors, such as the extensive consumption of other toxic substances, the lack of dental care, and socioeconomic restrictions, might be associated with the severe intraoral consequences that occur in the case of chronic methamphetamine abuse. Therefore, when methamphetamine is abused over a long period of time and in the absence of treatment, clinical symptoms in terms of “Meth Mouth” syndrome cannot be excluded, particularly in combination with other possible direct pathogenic effects of the substance methamphetamine. The authors recommend the development of a specific prevention and therapeutic concept including educational campaigns for methamphetamine abusers and specific dental treatment for this patient group. Role of funding sources This study was funded by internal funding sources of the Department of Oral and Maxillofacial Surgery, Munich University of Technology. It was also supported by funding provided by the Koinor Horst Mueller Foundation. These funding bodies had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors The study concept was developed by Marco Kesting (MK), Nils H. Rohleder (NRH), Niklas Rommel (NR) and Roland Härtel-Petri (RP). MK, NHR, NR and RP developed the questionnaire. RP, NR and NHR recruited participants and collected data. The complete statistical analysis was performed by Stefan Wagenpfeil (SW). NR wrote the first draft of
N. Rommel et al. / Addictive Behaviors 50 (2015) 182–187 the paper and all other authors critically revised it and approved the final submitted version. Conflict of interest All authors declare that they have no conflict of interest. Acknowledgments The authors wish to thank Annegret Sievert for assistance with acquiring participants; Stefanie Lukas for supporting the study organization; and Theresa Jones for the final language correction of the manuscript.
References Brand, H. S., Dun, S. N., & Nieuw Amerongen, A. V. (2008). Ecstasy (MDMA) and oral health. British Dental Journal, 204, 77–81. Brand, H. S., Gonggrijp, S., & Blanksma, C. J. (2008). Cocaine and oral health. British Dental Journal, 204, 365–369. Brown, R. E., Morisky, D. E., & Silverstein, S. J. (2013). Meth mouth severity in response to drug-use patterns and dental access in methamphetamine users. Journal of the California Dental Association, 41, 421–428. Chapman, C. R., Lipschitz, D. L., Angst, M. S., Chou, R., Denisco, R. C., Donaldson, G. W., et al. (2010). Opioid pharmacotherapy for chronic non-cancer pain in the United States: A research guideline for developing an evidence-base. The Journal of Pain, 11, 807–829. Curtis, E. K. (2006). Meth mouth: A review of methamphetamine abuse and its oral manifestations. General Dentistry, 54, 125–129 (quiz 130). Darling, M. R. (2003). Cannabis abuse and oral health care: Review and suggestions for management. SADJ, 58, 189–190. Donaldson, M., & Goodchild, J. H. (2006). Oral health of the methamphetamine abuser. American Journal of Health-System Pharmacy, 63, 2078–2082. Dye, B. A., Tan, S., Smith, V., Lewis, B. G., Barker, L. K., Thornton-Evans, G., et al. (2007). Trends in oral health status: United States, 1988–1994 and 1999–2004. Vital and Health Statistics, 11, 1–92. Fox, P. C. (2008). Xerostomia: Recognition and management. Dental Assistant, 77 (18, 20, 44-18; quiz 50-11). Hamamoto, D. T., & Rhodus, N. L. (2009). Methamphetamine abuse and dentistry. Oral Diseases, 15, 27–37. Hellwig, E., Klimek, J., & Attin, T. (2003). Introduction in conservative dentistry (3rd ed.). München: Urban & Fischer. Kirby, T., & Thornber-Dunwell, M. (2013). High-risk drug practices tighten grip on London gay scene. Lancet, 381, 101–102. Laslett, A. M., & Crofts, J. N. (2007). Meth mouth. Medical Journal of Australia, 186, 661. Padilla, R., & Ritter, A. V. (2008). Meth mouth: Methamphetamine and oral health. Journal of Esthetic and Restorative Dentistry, 20, 148–149. Police Crime Statistics for Upper Franconia (March 8th 2013). Retrieved on August 21, 2013 from http://www.polizei.bayern.de/oberfranken/kriminalitaet/statistik/index. html/174 005
187
Ramesh, A., & Ganguly, R. (2011). Sequence of events: Caries to osteomyelitis. Journal of the Massachusetts Dental Society, 60, 42–43. Ravenel, M. C., Salinas, C. F., Marlow, N. M., Slate, E. H., Evans, Z. P., & Miller, P. M. (2012). Methamphetamine abuse and oral health: A pilot study of “meth mouth”. Quintessence International, 43, 229–237. Rawson, R. A., Gonzales, R., Marinelli-Casey, P., & Ang, A. (2007). Methamphetamine dependence: A closer look at treatment response and clinical characteristics associated with route of administration in outpatient treatment. American Journal on Addictions, 16, 291–299. Rhodus, N. L., & Little, J. W. (2005). Methamphetamine abuse and “meth mouth”. Northwest Dentistry, 84 (29, 31, 33-27). Rhodus, N. L., & Little, J. W. (2008). Methamphetamine abuse and “meth mouth”. Pennsylvania Dental Journal, 75, 19–29. Schifano, F., Corkery, J. M., & Cuffolo, G. (2007). Smokable (“ice”, “crystal meth”) and non smokable amphetamine-type stimulants: Clinical pharmacological and epidemiological issues, with special reference to the UK. Annali dell Istituto Superiore di Sanita, 43, 110–115. Shaner, J. W., Kimmes, N., Saini, T., & Edwards, P. (2006). “Meth mouth”: Rampant caries in methamphetamine abusers. AIDS Patient Care and STDs, 20, 146–150. Shetty, V., Mooney, L. J., Zigler, C. M., Belin, T. R., Murphy, D., & Rawson, R. (2010). The relationship between methamphetamine use and increased dental disease. Journal of the American Dental Association, 141, 307–318. Talloczy, Z., Martinez, J., Joset, D., Ray, Y., Gacser, A., Toussi, S., et al. (2008). Methamphetamine inhibits antigen processing, presentation, and phagocytosis. PLoS Pathogens, 4, e28. Tipton, D. A., Legan, Z. T., & Dabbous, M. (2010). Methamphetamine cytotoxicity and effect on LPS-stimulated IL-1beta production by human monocytes. Toxicology In Vitro, 24, 921–927. Turkyilmaz, I. (2010). Oral manifestations of “meth mouth”: A case report. Journal of Contemporary Dental Practice, 11, E073–E080. Vearrier, D., Greenberg, M. I., Miller, S. N., Okaneku, J. T., & Haggerty, D. A. (2012). Methamphetamine: History, pathophysiology, adverse health effects, current trends, and hazards associated with the clandestine manufacture of methamphetamine. Disease-a-Month, 58, 38–89. Verhaaren, H., Claeys, G., Verschraegen, G., de Niel, C., Leroy, J., & Clement, D. (1989). Endocarditis from a dental focus. Importance of oral hygiene in valvar heart disease. International Journal of Cardiology, 23, 343–347. Wickholm, S., Galanti, M. R., Soder, B., & Gilljam, H. (2003). Cigarette smoking, snuff use and alcohol drinking: Coexisting risk behaviours for oral health in young males. Community Dentistry and Oral Epidemiology, 31, 269–274. Zaclikevis, M. V., D'Agulham, A. C., Bertassoni, L. E., Machado, M. A., de Lima, A. A., Gregio, A. M., et al. (2009). Effects of benzodiazepine and pilocarpine on rat parotid glands: Histomorphometric and sialometric study. Medicinal Chemistry, 5, 74–78.
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Addictive Behaviors
Evaluation of methamphetamine-associated socioeconomic status and addictive behaviors, and their impact on oral health Niklas Rommel a,⁎, Nils H. Rohleder a, Stefan Wagenpfeil b, Roland Haertel-Petri c, Marco R. Kesting a a b c
Department of Oral and Maxillofacial Surgery, Munich University of Technology, Ismaninger Str. 22, D-81675 Munich, Germany Institute for Medical Biometry, Epidemiology and Medical Informatics, University of Saarland at Homburg/Saar, Kirrberger Straße 100, D-66424 Homburg/Saar, Germany Department of Addiction Medicine, Hospital for Psychiatry, Psychotherapy, Psychosomatic Medicine, and Neurology, Nordring 2, D-954, 44 Bayreuth, Germany
H I G H L I G H T S • • • •
MA abuse is connected with a higher risk for intraoral health damaging. We found lower socioeconomic status in MA abusers compared with non-abusers. MA abuse is strongly associated with the consumption of other addictive substances. We detected an absence of dental care among chronic MA abusers.
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Article history: Received 14 January 2015 Received in revised form 12 April 2015 Accepted 16 June 2015 Available online 26 June 2015 Keywords: Methamphetamine Socioeconomic status Consumption behavior Dental care Oral health
a b s t r a c t Background: Chronic methamphetamine abuse can lead to multiple health hazards. In particular, the substance is associated with devastating effects on oral health including symptoms such as rampant caries, gingiva inflammation, and xerostomia, whereby the term “Meth Mouth” occurs in the current literature. However, “Meth Mouth” pathology is primarily described on the basis of individual cases or has been evaluated without consideration of the mass of potential influencing factors. Therefore, we have conducted a systematic study to investigate the effects of accompanying factors and circumstances on oral health in cases of chronic methamphetamine abuse. Methods: In cooperation with two centers for addiction medicine, we assessed the data of 100 chronic methamphetamine users and 100 matched-pair controls between March 2012 and November 2013. We investigated their socioeconomic status, details of methamphetamine consumption behavior, collateral consumption of sugar beverages, nicotine alcohol, and other addictive substances including cannabis, opioids, other stimulants, and hallucinogens, and dental care. Results: We found considerably greater unstable social circumstances, a high collateral consumption of substances with pathogenic potential for the stomatognathic system, and significantly poorer dental care in the methamphetamine-user group. Conclusions: Various factors have to be considered with regard to methamphetamine use and its influence on oral health. These factors can trigger potential damage by the drug methamphetamine possibly leading to the symptoms of “Meth Mouth”, and should be considered in prevention and therapy strategies. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction 1.1. The prevalence of the substance methamphetamine The highly-addictive substance methamphetamine is a widespread and serious problem in many countries (Turkyilmaz, 2010). Currently, the prevalence of methamphetamine abuse is estimated at 10 million
⁎ Corresponding author. Tel.: +49 4140 9744; fax: +49 89 4140 2934. E-mail address: [email protected] (N. Rommel).
http://dx.doi.org/10.1016/j.addbeh.2015.06.040 0306-4603/© 2015 Elsevier Ltd. All rights reserved.
people in the United States and 35 million people worldwide (Talloczy et al., 2008). Methamphetamine is illegally traded and widely abused under the scene name “crystal” or “crystal methamphetamine”. Particularly in Europe, the abuse of crystal methamphetamine is rapidly spreading. The police seized 3198.41 g crystal methamphetamine in German border areas to the Czech Republic within the year 2012; this represents an increase of almost 200% in a two-year comparison with 2010 (Police Crime Statistics for Upper Franconia, 2013). Furthermore, in the UK, the abuse of methamphetamine is currently on a large rise in London's Gay Scene and, consequently, puts men at a higher risk of infections (Kirby & Thornber-Dunwell, 2013).
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1.2. Consequences of chronic methamphetamine abuse The chronic use of methamphetamine involves a wide range of potential health hazards including massive weight loss, chronic skin irritations, cardiovascular diseases, structural brain damage, paranoia, or depression (Hamamoto & Rhodus, 2009). Recently, however, the severe consequences of chronic methamphetamine abuse has been described and, in particular, those on the stomatognathic system, which consists of the mouth, teeth, intraoral tissue, and jaws (Curtis, 2006; Donaldson & Goodchild, 2006; Hamamoto & Rhodus, 2009). The term “Meth Mouth” first appeared in the professional literature in 2005 based on findings in the United States (Rhodus & Little, 2005). From that moment to the present date, many authors have drawn attention to the probability of “Meth Mouth” occurrence after chronic methamphetamine abuse (Ravenel et al., 2012; Shaner, Kimmes, Saini, & Edwards, 2006; Turkyilmaz, 2010) including symptoms of rampant caries (Hamamoto & Rhodus, 2009) and extensive gingiva inflammation and parodontitis (Rhodus & Little, 2008; Tipton, Legan, & Dabbous, 2010). These symptoms lead to further health consequences if they are not treated timely and adequately. Progressive caries and oral tissue inflammation can result in massive pain and in complete tooth loss, both of which will influence nutrition behavior significantly. Especially in cases of chronic methamphetamine abuse, this is alarming. Sympathomimetic effects of the drug cause appetite suppression, sleep deprivation, and sensations of intense energy that lead to weight loss (Padilla & Ritter, 2008; Vearrier, Greenberg, Miller, Okaneku, & Haggerty, 2012). In combination with the severe consequences on oral health described above, weight loss will be triggered significantly with life-threatening potential. Furthermore, chronic and progressive caries lesions and inflammation of the oral tissue can spread into other regions of the body and result in dangerous infections such as endocarditis (Verhaaren et al., 1989) or osteomyelitis of the jaws (Ramesh & Ganguly, 2011). At the very least, severe oral conditions are often associated with prejudice and make the social rehabilitation process more difficult for the ex-abuser.
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Therefore, the aim of the study has been to evaluate these various possible influencing factors on oral health in cases of chronic methamphetamine abuse. First, the social status of a typical methamphetamine should be considered. Second, the addictive behavior with respect to the substance methamphetamine, high-sugar beverages, other addictive substances, nicotine, and alcohol should be investigated. Third, the dental care of a typical methamphetamine abuser should be screened. Subsequently, an evaluation should be made as to whether these factors contribute to the “Meth Mouth” phenomenon. To gain an indication of whether a “Meth Mouth” syndrome even exists, we have questioned methamphetamine abusers about oral conspicuities from start of their methamphetamine abuse and requested that abusers should asses their current oral health status. The “Meth Mouth” has primarily been evaluated on the basis of individual case reports, with a lack of conclusive relationships being shown between chronic methamphetamine abuse and oral diseases. Systematic study designs in this field are rare, not least because of the difficult access to a large number of methamphetamine abusers. We have established a collaboration between specialty institutions for addiction medicine and oral medicine in order to conduct a systematic and extensive questionnaire and patient interview including a sufficient number of methamphetamine participants. Furthermore, for optimal comparability of data, we have recruited a matched-pair control participant for each methamphetamine abuser and carried out the complete data analysis in cooperation with a university statistical institute. 2. Methods The study collaboration consisted of the two specialty clinics for addiction medicine in Bayreuth, Germany and Hochstadt/Main, Germany, the Department of Oral and Maxillofacial Surgery of the Munich University of Technology, Germany and the Institute for Medical Biometry, Epidemiology and Medical Informatics of the University of Saarland, Germany. 2.1. Participants
1.3. Potential causes of the “Meth Mouth” phenomenon Various hypotheses for the “Meth Mouth” phenomenon and its symptoms have been suggested. The pharmacologic effects of the drug seem to be one explanation. Methamphetamine blocks the re-uptake of norepinephrine and dopamine and subsequently stimulates the sympathetic nervous system (Donaldson & Goodchild, 2006; Hamamoto & Rhodus, 2009). With regard to the oral region, the consequences are dry mouth (Donaldson & Goodchild, 2006) or extensive grinding of the teeth (Curtis, 2006). Dry mouth is associated with the loss of important protective properties of saliva such as the neutralization of plaque-induced acids and the remineralization of dental enamel, and therefore, dry mouth substantially increases the risk of caries (Fox, 2008). A massive decline of saliva production is considered to play a crucial role in methamphetamine-associated tooth decay (Shaner et al., 2006). In this context, the intake of high-sugar beverages is also considered to be responsible for the excessive tooth wear in methamphetamine abusers (Rhodus & Little, 2005). However, no systematic study designs exist determining whether methamphetamine abusers drink more high-sugar beverages than non-abusers. Additionally, we do not know whether other potential influencing factors on oral health, such as social status or the co-consumption of nicotine, alcohol, or other addictive substances, contribute to these described oral health hazards in a methamphetamine abuser. A lack of dental care and the nonrecognition of the oral health damage might also play a significant role in “Meth Mouth” and have not as yet been evaluated in cases of chronic methamphetamine abuse. Nevertheless, differences in the pathogenic potential of the substance have been described as being dependent on the individual form of methamphetamine consumed (Rawson, Gonzales, Marinelli-Casey, & Ang, 2007).
In order to attain sufficient statistical power and to be able to present data directly in percent, 200 participants consisting of 100 methamphetamine abusers and 100 matched-pair non-users were selected and examined between March 2012 and November 2013. The selection and data acquisition of the methamphetamine abusers took place at the addiction clinics, with the individuals in separate rooms in a quiet atmosphere. First, the executive psychotherapist in each addiction clinic checked the eligibility criteria for this study for the methamphetamine group in a short patient interview. The criteria included constant methamphetamine abuse of 1 g/week for more than a minimum period of 12 months without any withdrawal periods. Additionally, a potential participant had to have reached the 18th year of age, and each methamphetamine abuser was informed that study participation would be absolutely voluntary. If a methamphetamine abuser did not fulfill the eligibility criteria or did not consent to study participation, then he or she was selected out by the executive psychotherapist. All methamphetamine abusers who fulfilled all eligibility criteria and gave written consent to study participation received a detailed questionnaire including three different sections (see 2.2. Data collection); this questionnaire was filled out by the participant. Subsequently, a personal conversation between the methamphetamine abuser, a physician, and a psychotherapist was conducted in order to clarify any existing ambiguities in the questions. The complete data collection including selection, the question and answer section, and the personal conversation took 100 min, on average. The average age of the participants was 29.5 years (SD ± 7.0) with a gender distribution of 17 females and 83 males. For the control group, we defined the matched-pair criteria of gender and age (+/− 1a) and recruited its participants from resident patients at the University Hospital in Munich and from patients of two residential
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Table 1 Data of socioeconomic backgrounds (CM = crystal meth). CM group (n = 100)
Control group (n = 100)
Total (n = 200)
p-Value (statistical test)
Marital status Single Married Remarried Separated Divorced Widowed
% 82 9 1 4 1 3
% 86 14 0 0 0 0
% 84 11.5 0.5 2 0.5 1.5
0.031 (Fisher's exact test)
Current residence Single accommodation Parents/relatives Sharing Homeless Unclear
% 46 32 3 12 7
% 70 19 11 0 0
% 58 25.5 7 6 3.5
b0.001 (Fisher's exact test)
Vocational education University degree Vocational school A-level B-level Secondary modern school No education
% 0 7 5 22 51 15
% 21 4 44 17 14 0
% 10.5 5.5 24.5 19.5 32.5 7.5
b0.001 (Mann–Whitney-U-test)
Job situation Fully employed Part-time work Apprenticeship University student School student Unemployed Unclear
% 17 7 5 0 0 65 6
% 49 9 15 22 2 3 0
% 33 8 10 11 1 34 3
b0.001 (Fisher's exact test)
Subsistence finances Occupation Unemployment benefits Income support Child allowance Relatives/friends Student subsidy Illegal earnings Other
% 18 51 15 4 2 0 3 7
% 66 0 0 9 15 3 0 7
% 42 25.5 7.5 6.5 8.5 1.5 1.5 7
b0.001 (Fisher's exact test)
dental surgeries in Munich. Analog to the methamphetamine group, the eligibility criteria were first checked, followed by the answering of the detailed questionnaire and the personal conversation. Selection and data collection of the control group were performed by two physicians of the University Hospital in Munich. All study participants received an information document including objectives of the study. According to the requirements of the ethics committee, we informed each participant about data use and data protection and obtained his or her written consent to participation in the study.
and reduced salivary flow. Additionally, methamphetamine abusers were asked to indicate whether other methamphetamine abusers in their social environment noticed the symptoms described above.
2.2. Data collection
Table 2 Special data with regard to crystal meth users (n = 100).
In the first section, both groups gave detailed information about their socioeconomic status (SES) including marital status, current residence, vocational education, job situation, and subsistence finances. In the second section, both groups gave detailed information about their consumption of nicotine and alcohol and of high-sugar beverages. The methamphetamine group was additionally asked about the period of the time, frequency, duration, and patterns of individual methamphetamine abuse and the accompanying consumption of other addictive drugs including cannabis, other stimulants, sedatives, or hallucinogens. In the third section, both groups were asked to assess their dental health status and to indicate the date of their last check-up. Methamphetamine abusers, in particular, were requested to specify any noticed conspicuity with regard to their teeth and the mouth and maxilla region directly linked to their methamphetamine consumption, including the symptoms “teeth fragility”, gingiva bleeding, pain in the jaw joints,
2.3. Statistical analysis We used the Mann–Whitney-U-test and Fisher's exact test for testing statistical significance. For each parameter, an adequate
Route of crystal meth administration Intranasal Smoking Intravenous Others
% 91 34 33 4
Consumption of other addictive substances Cannabis/marihuana Stimulants Opioids and sedatives Hallucinogens
% 56 42 22 12
Abnormalities within the stomatognathic system since the beginning of crystal meth use Noticed “teeth fragility” Noticed increased gingiva bleeding Noticed increased pain in the jaw joint Noticed reduced salivary flow Noticed disorders within the oral cavity and jaw joints in other users
% 68 43 46 71 75
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Table 3 Data with regard to consumption of nicotine, alcohol and high-sugar beverages and to dental care. CM group (n = 100)
Control group (n = 100)
Total (n = 200)
p-Value (statistical test)
Smokers Yes No
% 79 21
% 34 66
% 56.5 43.5
b0.001 (Fisher's exact test)
Alcohol consumption Daily Frequently (3–6 times/week) Sometimes (1–2 times/week) Rarely (b3 times/month) No consumption
% 11 10 35 31 13
% 1 3 52 12 32
% 6 6.5 43.5 21.5 22.5
0.019 (Mann–Whitney-U-test)
Consumption of sugar beverages Daily Frequently (3–6 times/week) Sometimes (1–2 times/week) Rarely (b3 times/month) No consumption
% 6 3 33 10 48
% 19 11 22 8 40
% 12.5 7 27.5 21.5 22.5
0.14 (Fisher's exact test)
Self-assessment of dental health Very good Passable In need of improvement Poor Very poor
% 3 16 49 20 12
% 18 43 31 8 0
% 10.5 29.5 40 14 6
b0.001 (Mann–Whitney-U-test)
Date of last professional dental check Within the last 12 month 1 year ago 2 years ago Longer than 2 years ago
% 34 28 14 24
% 66 18 5 11
% 50 23 9.5 17
b0.001 (Fisher's exact test)
Regularity of dental check-ups Regular visits to the dentist
% 31
% 83
% 62
b0.001 (Fisher's exact test)
statistical test was selected. P-values were two-sided and subjected to a significance level of 0.05. We used the software programs SPSS 21.0. (Fa. IBM, Armonk, USA) and Cytel Studio version 10 (Fa. Cytel, Cambridge, USA) for the statistical analysis and Excel 2010 for data transfer and handling. For data regarding professional education, frequency of drinking sugary beverages, and consumption of alcohol, we used the Mann– Whitney U-test comparing medians. For the data of partnerships, current residence, employment, financing of subsistence, consumption of sugary beverages, smoking status, and dates and regularity of dental checks, we used Fisher's exact test comparing relative frequencies. The data that only affected the methamphetamine-abuser-group including frequency, form, and duration of consumption and additional use of other drugs since the beginning of methamphetamine use were assessed purely descriptively without using an inferential procedure. 3. Results We found that chronic methamphetamine usage was associated with considerably more unstable social circumstances than in a sameaged and same-gender person without chronic methamphetamine abuse. In particular, the current employment situation of the methamphetamine abusers was dramatically different, with an unemployment rate of 65% (Table 1). By far the most common route of methamphetamine intake was intranasal administration, which was employed by 91% of all studied methamphetamine abusers. Of all methamphetamine abusers, 76% said that they regularly also used other addictive substances such as cannabis, sedatives, stimulants, or hallucinogens, with cannabis being the most common (56%) as shown in Table 2. Most methamphetamine abusers had noticed multiple abnormalities within the oral cavity and the jaw joints since the start of methamphetamine use (Table 2). A significantly higher percentage of smokers
could be observed within the methamphetamine group (79%) compared with the control group (34%). Furthermore, 21% of all methamphetamine abusers said that they drank alcohol frequently (4–6 times/week) or even daily. However, we found no increased drinking of sugary beverages with regard to chronic methamphetamine abuse. Only 31% of all methamphetamine abusers were under regular dental supervision (control group 83%), although 81% of the methamphetamine abusers rated their individual tooth status as “in need of improvement” or even worse (Table 3). 4. Discussion We found a significant number of accompanying factors with pathogenic potential for oral diseases including unstable socioeconomic conditions with financial constraints, consumption of other addictive toxic substances, and a lack of professional dental care in the case of chronic methamphetamine abuse. Most of the methamphetamine abusers noticed “Meth Mouth”-specific abnormalities within the oral region and the jaw joints from the beginning of methamphetamine consumption. Additionally, methamphetamine abusers rated their tooth status as being significantly worse than a comparable group of non-abusers. These findings are an indication of the damaging effects of chronic methamphetamine abuse and are in agreement with previous presumptions (Donaldson & Goodchild, 2006; Hamamoto & Rhodus, 2009). Research results and empirical data show that dental pain, damaged teeth, and the incidence of caries appear in the event of decreased socioeconomic status and homelessness, and that, in cases of a lack of access to health care, these problems lead to poor oral health (Dye et al., 2007). During our study, each methamphetamine abuser reported more unstable social conditions compared with a test person of the same age; this leads to the inference that the risk of oral diseases is generally increased in the methamphetamine group. Additionally, only 31% of all methamphetamine abusers indicated that they
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underwent regular dental treatment (comparable control group: 83%) and only 34% visited a dentist within the last 12 months (comparable control group: 66%), although most of the methamphetamine abusers noticed a change in their oral cavity related to their chronic methamphetamine abuse and deemed their dental state as an area for improvement or even as being bad. A lack of compliance of the methamphetamine abusers in an acute phase of consumption could be relevant. Excessive fear of the dentist and feelings of shame also have to be considered. However, financial limitations because of an often low socioeconomic status seem to reduce the possibilities of adequate dental therapy for the methamphetamine group. This factor is even present in countries such as Germany in which therapeutic measures are provided, even in cases of weak social status, because of the availability of extensive public health care and health insurance systems and statutory health insurance. Specific supporting concepts for prevention and therapy during methamphetamine abuse are thus necessary. With regard to additional illegal drug consumption, most methamphetamine abusers in this study indicated that they also regularly consumed other addictive drugs such as cannabis, sedatives, stimulants, or hallucinogens. Cannabis consumers exhibit a higher risk for caries and dry mouth (Darling, 2003). Increased gingival lesions and dental erosions are postulated as an effect of cocaine on oral health (Brand, Gonggrijp, & Blanksma, 2008). In the case of ecstasy consumption, dry mouth and increased dental erosions are more prevalent (Brand, Dun, & Nieuw Amerongen, 2008). Long-term opioid consumption can induce dry mouth (Chapman et al., 2010), as can the consumption of tranquilizers such as benzodiazepine (Zaclikevis et al., 2009). In summary, the extensive additional abuse of other substances such as cannabis, other stimulants, opioids, or tranquilizers has to be considered as a relevant trigger factor for caries lesions, oral tissue inflammation, dry mouth, and subsequently substantial tooth decay in methamphetamine abusers. Smokers, who accounted for 79% of all methamphetamine test persons in our study, also have an increased risk of caries. Importantly, the combination of alcohol and nicotine can cause severe intraoral changes in the form of caries, gingival inflammation, and precanceroses (Wickholm, Galanti, Soder, & Gilljam, 2003). The results of this study show that the risk of intraoral diseases is increased solely by the corollary consumption of nicotine and, at times, the excessive corollary consumption of alcohol. Alcohol and nicotine intake might thus also play an important role in the devastating effects of chronic methamphetamine abuse on oral health. High-sugar intake, mainly in the form of high-sugary beverages in order to compensate for the methamphetamine-induced dry mouth, is considered to be the main reason for rapid tooth decay during periods of methamphetamine abuse (Hamamoto & Rhodus, 2009; Padilla & Ritter, 2008). Furthermore, one case report has described a young man with rampant carious lesions, dry mouth, and excessive consumption of high-sugar beverages related to methamphetamine abuse for one year (Shaner et al., 2006). We have found no increased consumption of sugary beverages within the methamphetamine group compared with the control group and, thus, cannot confirm this assumption. However, our participants were only asked about the consumption of sugary beverages and not about their consumption of sugar in detail. Therefore, consumption of other high-sugary substances among methamphetamine abusers cannot be excluded and requires further research. Additionally, individual oral hygiene has to be taken into account in this context. Oral hygiene including correct and regular dental care is an important prevention measure with regard to oral diseases (Hellwig, Klimek, & Attin, 2003). In the case of “Meth Mouth” syndrome, many authors report the strong neglect or complete lack of oral hygiene measures in methamphetamine abusers (Donaldson & Goodchild, 2006; Laslett & Crofts, 2007; Rhodus & Little, 2008). However, these findings are primarily based on case reports with no systematic questionnaire and patient interview, including clinical supervision. A
clinic oral hygiene index combined with a detailed nutrition questionnaire and patient interview might be useful in such studies. Another factor relevant with regard to the implications and consequences of methamphetamine abuse is the method of methamphetamine administration. Methamphetamine can be snorted, smoked, swallowed, dissolved in water, or applied intravenously (IV) or perianally (Schifano, Corkery, & Cuffolo, 2007). Rawson et al. (2007) have examined the consequences of the various methods of methamphetamine administration with regard to psychological and medical impairment and detected IV abuse as being the most highly damaging, closely followed by the smoking of methamphetamine. In comparison with the other two methods of abuse, intranasal abuse displays the least damaging effect (Rawson et al., 2007). With regard to oral diseases and methamphetamine administration, however, different views exist. Shetty et al. (2010) have found the most highly damaging effects to occur with IV abuse, followed by intranasal abuse and smoking, whereas Brown, Morisky, and Silverstein (2013) suggest that the most damaging effects occur after smoking, because of direct oral exposure. In our study, intranasal methamphetamine abuse was dominant followed by smoking and IV abuse. With regard to reported abnormalities within the stomatognathic system and the self-assessment data of methamphetamine abusers in this study, intranasal abuse is also likely to have a high damaging potential. However, we have performed no clinical examination that can confirm this assumption. Nevertheless, in the context of previous observations and from the reports of methamphetamine abusers in this study, we consider that the total dose of methamphetamine is more crucial for oral diseases than any direct effects within the oral cavity. Our findings have to be considered in context with the following study limitations. The data collection took place retrospectively, and so we had to rely on the truthful answers of all study participants; therefore, potential information bias cannot be ruled out. Furthermore, we performed no clinical investigation, and thus, no statement can be made about the clinical consequences of chronic methamphetamine abuse described in previous studies. Our findings with respect to oral abnormalities in methamphetamine abusers and the data concerning the self-assessment of oral health are an indication for specific oral health damage but are not sufficiently conclusive. We recommend a systematic longitudinal study including a detailed clinical examination combined with extensive questionnaire and patient interview with regard to all potential influencing factors in order to improve knowledge of the effects of this drug. In conclusion, many accompanying risk factors, such as the extensive consumption of other toxic substances, the lack of dental care, and socioeconomic restrictions, might be associated with the severe intraoral consequences that occur in the case of chronic methamphetamine abuse. Therefore, when methamphetamine is abused over a long period of time and in the absence of treatment, clinical symptoms in terms of “Meth Mouth” syndrome cannot be excluded, particularly in combination with other possible direct pathogenic effects of the substance methamphetamine. The authors recommend the development of a specific prevention and therapeutic concept including educational campaigns for methamphetamine abusers and specific dental treatment for this patient group. Role of funding sources This study was funded by internal funding sources of the Department of Oral and Maxillofacial Surgery, Munich University of Technology. It was also supported by funding provided by the Koinor Horst Mueller Foundation. These funding bodies had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors The study concept was developed by Marco Kesting (MK), Nils H. Rohleder (NRH), Niklas Rommel (NR) and Roland Härtel-Petri (RP). MK, NHR, NR and RP developed the questionnaire. RP, NR and NHR recruited participants and collected data. The complete statistical analysis was performed by Stefan Wagenpfeil (SW). NR wrote the first draft of
N. Rommel et al. / Addictive Behaviors 50 (2015) 182–187 the paper and all other authors critically revised it and approved the final submitted version. Conflict of interest All authors declare that they have no conflict of interest. Acknowledgments The authors wish to thank Annegret Sievert for assistance with acquiring participants; Stefanie Lukas for supporting the study organization; and Theresa Jones for the final language correction of the manuscript.
References Brand, H. S., Dun, S. N., & Nieuw Amerongen, A. V. (2008). Ecstasy (MDMA) and oral health. British Dental Journal, 204, 77–81. Brand, H. S., Gonggrijp, S., & Blanksma, C. J. (2008). Cocaine and oral health. British Dental Journal, 204, 365–369. Brown, R. E., Morisky, D. E., & Silverstein, S. J. (2013). Meth mouth severity in response to drug-use patterns and dental access in methamphetamine users. Journal of the California Dental Association, 41, 421–428. Chapman, C. R., Lipschitz, D. L., Angst, M. S., Chou, R., Denisco, R. C., Donaldson, G. W., et al. (2010). Opioid pharmacotherapy for chronic non-cancer pain in the United States: A research guideline for developing an evidence-base. The Journal of Pain, 11, 807–829. Curtis, E. K. (2006). Meth mouth: A review of methamphetamine abuse and its oral manifestations. General Dentistry, 54, 125–129 (quiz 130). Darling, M. R. (2003). Cannabis abuse and oral health care: Review and suggestions for management. SADJ, 58, 189–190. Donaldson, M., & Goodchild, J. H. (2006). Oral health of the methamphetamine abuser. American Journal of Health-System Pharmacy, 63, 2078–2082. Dye, B. A., Tan, S., Smith, V., Lewis, B. G., Barker, L. K., Thornton-Evans, G., et al. (2007). Trends in oral health status: United States, 1988–1994 and 1999–2004. Vital and Health Statistics, 11, 1–92. Fox, P. C. (2008). Xerostomia: Recognition and management. Dental Assistant, 77 (18, 20, 44-18; quiz 50-11). Hamamoto, D. T., & Rhodus, N. L. (2009). Methamphetamine abuse and dentistry. Oral Diseases, 15, 27–37. Hellwig, E., Klimek, J., & Attin, T. (2003). Introduction in conservative dentistry (3rd ed.). München: Urban & Fischer. Kirby, T., & Thornber-Dunwell, M. (2013). High-risk drug practices tighten grip on London gay scene. Lancet, 381, 101–102. Laslett, A. M., & Crofts, J. N. (2007). Meth mouth. Medical Journal of Australia, 186, 661. Padilla, R., & Ritter, A. V. (2008). Meth mouth: Methamphetamine and oral health. Journal of Esthetic and Restorative Dentistry, 20, 148–149. Police Crime Statistics for Upper Franconia (March 8th 2013). Retrieved on August 21, 2013 from http://www.polizei.bayern.de/oberfranken/kriminalitaet/statistik/index. html/174 005
187
Ramesh, A., & Ganguly, R. (2011). Sequence of events: Caries to osteomyelitis. Journal of the Massachusetts Dental Society, 60, 42–43. Ravenel, M. C., Salinas, C. F., Marlow, N. M., Slate, E. H., Evans, Z. P., & Miller, P. M. (2012). Methamphetamine abuse and oral health: A pilot study of “meth mouth”. Quintessence International, 43, 229–237. Rawson, R. A., Gonzales, R., Marinelli-Casey, P., & Ang, A. (2007). Methamphetamine dependence: A closer look at treatment response and clinical characteristics associated with route of administration in outpatient treatment. American Journal on Addictions, 16, 291–299. Rhodus, N. L., & Little, J. W. (2005). Methamphetamine abuse and “meth mouth”. Northwest Dentistry, 84 (29, 31, 33-27). Rhodus, N. L., & Little, J. W. (2008). Methamphetamine abuse and “meth mouth”. Pennsylvania Dental Journal, 75, 19–29. Schifano, F., Corkery, J. M., & Cuffolo, G. (2007). Smokable (“ice”, “crystal meth”) and non smokable amphetamine-type stimulants: Clinical pharmacological and epidemiological issues, with special reference to the UK. Annali dell Istituto Superiore di Sanita, 43, 110–115. Shaner, J. W., Kimmes, N., Saini, T., & Edwards, P. (2006). “Meth mouth”: Rampant caries in methamphetamine abusers. AIDS Patient Care and STDs, 20, 146–150. Shetty, V., Mooney, L. J., Zigler, C. M., Belin, T. R., Murphy, D., & Rawson, R. (2010). The relationship between methamphetamine use and increased dental disease. Journal of the American Dental Association, 141, 307–318. Talloczy, Z., Martinez, J., Joset, D., Ray, Y., Gacser, A., Toussi, S., et al. (2008). Methamphetamine inhibits antigen processing, presentation, and phagocytosis. PLoS Pathogens, 4, e28. Tipton, D. A., Legan, Z. T., & Dabbous, M. (2010). Methamphetamine cytotoxicity and effect on LPS-stimulated IL-1beta production by human monocytes. Toxicology In Vitro, 24, 921–927. Turkyilmaz, I. (2010). Oral manifestations of “meth mouth”: A case report. Journal of Contemporary Dental Practice, 11, E073–E080. Vearrier, D., Greenberg, M. I., Miller, S. N., Okaneku, J. T., & Haggerty, D. A. (2012). Methamphetamine: History, pathophysiology, adverse health effects, current trends, and hazards associated with the clandestine manufacture of methamphetamine. Disease-a-Month, 58, 38–89. Verhaaren, H., Claeys, G., Verschraegen, G., de Niel, C., Leroy, J., & Clement, D. (1989). Endocarditis from a dental focus. Importance of oral hygiene in valvar heart disease. International Journal of Cardiology, 23, 343–347. Wickholm, S., Galanti, M. R., Soder, B., & Gilljam, H. (2003). Cigarette smoking, snuff use and alcohol drinking: Coexisting risk behaviours for oral health in young males. Community Dentistry and Oral Epidemiology, 31, 269–274. Zaclikevis, M. V., D'Agulham, A. C., Bertassoni, L. E., Machado, M. A., de Lima, A. A., Gregio, A. M., et al. (2009). Effects of benzodiazepine and pilocarpine on rat parotid glands: Histomorphometric and sialometric study. Medicinal Chemistry, 5, 74–78.