The oral health effects of illegal drug abuse.

Jill is a 22-year-old woman, but she looks much older. She is facing her first incarceration. She is very thin; her cheeks are hollow and her eyes sunken. Jill's complexion is an unhealthy shade of pasty white and her arms have deep scratch marks. When she smiles, her eyes reveal the sparkle of what was once an attractive smile. But now all that is noticeable are her teeth. Several are completely brown and others are broken, blackened stubs. Almost all of them have dark cavities where the tooth and the gums meet. Her gums are fiery red. On the right side of her lower jaw is a round bump, a little larger than a marble.

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By now, everyone who has worked closely with offenders has seen someone like Jill. Many offenders with a history of substance abuse have serious oral health problems by the time they are incarcerated. Methamphetamine abusers often come to prison with their teeth devastated by decay. Other commonly abused drugs, such as heroin and cocaine, can also have a negative effect on oral health. What is happening to Jill and other offenders like her? Is the dental disease simply the result of the chaotic lifestyle and lack of self-care that often accompany drug abuse, or is it something more?

Consequences of Methamphetamine Use on Oral Health

To answer these questions, it is important to look at the effects of methamphetamine (meth) on the body. Meth dries out the mouth, and meth abusers often describe this as "cotton mouth" or "desert mouth." These are much more colorful terms than the medical one: xerostomia. But no matter what it is called, it is this lack of saliva that leads to tooth decay. Dentists commonly see xerostomia in patients who have had radiation therapy for head and neck cancer and in patients with Sjogrens Syndrome, who experience a general dryness of the mucous membranes.

Methamphetamine also suppresses the appetite. Users often use meth--or "tweak"--for several days at a time. While tweaking, they do not eat. During this time, the amount of sugar circulating in their blood plummets, so sufficient energy is not supplied to the cells. When they have been on the drug for two or three days without eating and then stop their drug use, users go through a time when they have low blood sugar levels and a very dry mouth, causing them to crave a stimulant. They report different solutions to this post-drug condition. Soda (such as Mountain Dew) and sweetened iced tea are popular options. These drinks contain caffeine and sugar, fulfilling the users' needs of the moment. However, they also can cause serious dental problems for teeth that likely have not been brushed or flossed during the users' tweaking. The sugar and liquid provide a perfect medium for the buildup of bacterial plaque on the surface of the teeth (aided by the dryness of the mouth), and tooth decay is the result.

This decay begins at the neck of the tooth, where it meets the gums. When it extends all the way around the tooth, the structural integrity of the tooth is compromised and another effect of methamphetamine comes into play: intense, uncontrolled muscle movements. These movements often cause meth users to clench their teeth together and grind their teeth. Dentists call this sort of tooth grinding bruxism. This puts extra force on the teeth, and the ones that are already structurally undermined may break. When they get to the dentist, methamphetamine abusers often say, "I don't know why, but my teeth just break off!"

Meth abusers also suffer from formication, which is the feeling that there are bugs under their skin. Those who suffer from it scratch themselves without mercy. This scratching occurs in the facial area as well as elsewhere and can cause scaring. One offender who had abused methamphetamine arrived at the Washington Corrections Center with a half-inch scar on his lip. He said that the scar was from pulling out a lip piercing adornment while he was on meth. He thought it was a fly under his skin. Sometimes users call the imaginary insects "meth bugs" or "meth mites."

"Meth mouth" is really tooth decay made far worse by the effects of methamphetamine. And untreated tooth decay leads to infection, painful cavities and tooth loss. This is exactly what happened to Jill. A friend had recommended that she try meth, saying that it would give her more energy and help her lose weight. The friend did not mention that it would make her look 10 or 15 years older or that her teeth would become decayed and infected. The friend did not warn her about the dental abscesses that woke her up in pain many times and gave her that marble-like bump on the jaw. Neither was Jill told that she would face incarceration because of her drug use.

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Consequences of Other Drug Use on Oral Health

As devastating to the mouth as methamphetamine is, it is not the only culprit. Heroin and cocaine abusers also experience rampant tooth decay. An informal study of the intake dental examination records of inmates admitted to the Washington Corrections Center for Women showed that when the decay history of drug abusers is compared with that of offenders who report no illegal drug history, the methamphetamine users have nine times as many seriously decayed teeth as the nonusers, while the heroin abuser has five times as many and the cocaine abuser has four times as many (see Figure 1).

Both heroin and cocaine produce a dry mouth condition similar to the effect of methamphetamine. They also may cause cravings for sugar. Many heroin users eat brown sugar by the spoonful. And drug abusers of all types tend to avoid toothbrushes, dental floss and the dentist. Indeed, abusers often use drugs to inhibit or mask the pain of their dental condition. Heroin can cause nausea and vomiting, which can lead to acid erosion of the teeth similar to that seen in people with bulimia, who intentionally vomit.

Several local anesthetics commonly used by dentists are derived from cocaine. So a person who goes to the dentist while on the drug, and who does not tell the dentist, can inadvertently receive an overdose. Some addicts know this, and it probably discourages them from seeking treatment.

Cocaine users also sometimes test the potency of their street drugs by placing a small amount of the drug on their gums. If the gum gets numb, they know the cocaine is good. But this can also burn the gums, causing a small round burned area where the cocaine was placed. The abusers of illegal drugs appear to have sore, red, swollen gums. Many of them are tobacco smokers as well as drug users, so some of this inflammation may be due to smoking. But it is not unusual to see the gum tissue of a drug user completely denuded from a lower front tooth.

One characteristic of street drugs is that they are not pure. Contaminants from the manufacturing process, or those added to cut the drug, may also produce undesirable effects. An offender at the Washington Corrections Center for Women had purple pigmentation on her gums along with other symptoms of arsenic poisoning. The arsenic had been added to her heroin in the belief that it would give the drug an aphrodisiac effect.

In addition, many intravenous drug abusers experience an infection inside their hearts called bacterial endocarditis. This may put them at further risk when dental treatment is undertaken without the administration of an antibiotic before the dental procedure.

Treatment

The dental needs of drug abusers are overwhelming the resources of many correctional dental clinics. Traditional dental treatment requires too much time, personnel and filling material to address all of the disease problems found in offenders. Fortunately, some of the problems can be addressed by other professionals responsible for the offender during incarceration to help the illegal drug abuser become healthier.

The first thing to remember is that the process causing damage to users' teeth is old-fashioned tooth decay. And there are other simple tools available to fight it. A toothbrush and dental floss are the most important weapons in this fight. In the correctional setting, security concerns about dental floss can be dealt with by using a special correctional floss substitute, such as Floss Loops, or by custody staff issuing and then collecting a 12- to 14-inch piece of floss.

The most important ingredient in toothpaste is fluoride, and all toothpaste supplied to offenders should contain it. Fluoride can be effectively used in other ways as well. Home rinses can be made available via the inmate store, and prescription-strength gels can be obtained from the pharmacy. Fluoride varnish painted on decayed areas can produce a remarkable decrease in the hot and cold sensitivity that results from decay. This can also retard or arrest the decay process. In the long term, the fluoridation of community water supplies will help as well.

Antimicrobial rinses, such as Chlorhexidine Gluconate (0.12 percent), used twice a day for two weeks can dramatically reduce the presence of decay-producing bacteria. Until recently the use of this tool in corrections was limited because it contained alcohol and thus could not be issued to inmates. However, Sunstar-Butler now markets an alcohol-free version of this valuable therapeutic agent.

Offenders with a high rate of tooth decay can be educated about dietary habits that encourage dental disease and how to change these habits. Such individuals need to reduce both the quantity and frequency of their consumption of sugary and starchy foods. They also must avoid chewing gum, hard candy, cough drops and breath mints that contain sugar. However, chewing gum or candy containing xylitol can be helpful. Xylitol is a special sugar that is destructive to decay-causing germs. Other sugarless products are not as helpful as xylitol when it comes to fighting tooth decay, so it is better to avoid them. Offenders also should be cautioned not to sip soda, sports drinks or other sugar-containing beverages, since sipping these slowly prolongs the time that a cavity-producing environment exists in the mouth. Although diet soda does not encourage tooth decay, it is acidic and can cause damage to tooth enamel.

The battle against dental disease in a correctional setting needs the help of the entire correctional team. Custody officers can encourage offenders to maintain their teeth while incarcerated. Nurses can emphasize the value of prevention and provide over-the-counter fluoride rinses. They can recommend saliva substitutes and home fluoride rinses for the short-term offender who is not yet committed to a drug-free lifestyle. Chemical dependency professionals can encourage healthy dental habits during chemical dependency treatment.

Corrections professionals working in facilities that house drug abusers for short periods meet offenders who are not ready to deal with their drug abuse and who may be in denial about it. These offenders can still benefit from good oral hygiene at home, fluoride rinses, and avoiding sugary beverages and snacks. Such drug users can use a saliva substitute such as Oasis or Biotene to help reduce dry mouth problems. Wearing an athletic mouth guard to protect against the wear and tear caused by uncontrolled muscle movements also will reduce the dental damage of drug abuse for these offenders.

As helpful as this team approach is, any facility that incarcerates drug abusers must have a dental treatment program. The program should provide all medically necessary care, including preventive dental care. Fillings and replacement teeth for long-term offenders should be offered. Because of the link between gum disease and heart disease, cleanings and other periodontal treatment are needed. A program where the only care offered is the extraction of painful teeth is not adequate.

Jill's Success

Jill came to the end of her incarceration a few months ago. For her, the prison experience was like a life preserver thrown to a drowning swimmer from a passing boat. She grabbed the ring. She finished her GED while in prison and completed a chemical dependency treatment program, which gave her the tools to deal with her addiction. Her complexion now has a healthy glow; she has achieved an appropriate weight; and the scars on her arms have healed. And some clever work by the prison dental staff has given Jill a smile that complements the sparkle in her eyes. She has a job as a waitress lined up and plans to begin studying at a community college. Everyone involved in her incarceration wishes her well as she returns to the community. That is why they call it corrections.

A.N. Morton, DDS, CCHP, is director of dental services for the Washington State Department of Corrections.