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An inclusive dental hygiene case of a recovered methamphetamine addict.

Methamphetamine is both a prescription and illegal drug that stimulates the central nervous system. It increases the release of dopamine and blocks its reuptake, leading to high levels of dopamine in the brain. Dopamine is a neurotransmitter responsible for the pleasure sensation. Individuals who use methamphetamine report an intense euphoria after using the drug. (1)

Just over 500,000 Americans report current use of methamphetamine, according to the 2009 National Survey on Drug Use and Health.2 This indicates an increase in methamphetamine use from the previous year's survey, but a decline in use since 2006. (2) The damage to the oral cavity from prior users will linger even if the number of users is declining. Many barriers to seeking treatment to repair the damage from methamphetamine use exist, including decreased access to care, financial resources, inability to take time off from work, and lack of motivation.

Introduction to the Case Client

A 39-year-old Caucasian male was treated at the University of Southern Indiana (USI) dental hygiene clinic in September 2009. He had not received dental hygiene therapy for over seven years. This client has a history of tobacco and methamphetamine use. The client stated that the last binge of methamphetamine use was when he noticed the generalized damage to his entire dentition. A binge was later defined as approximately one year of abuse. During a binge of using methamphetamine, he reported remaining awake for seven to 10 days before crashing and sleeping for 48 hours or more. Tooth brushing and oral care were a low priority while using methamphetamine. His preferred method of using methamphetamine was to smoke it. Smoking methamphetamine causes more severe damage to the anterior teeth since toxic and corrosive fumes from the drug directly contact those teeth while the drug is inhaled. (3) He has not used methamphetamine since going through a substance abuse program nine years ago. At the initial appointment, he smoked one to two packs of cigarettes per day.

This client was diagnosed with gradual onset plaque-induced localized mild periodontitis exacerbated by smoking and poor plaque removal with localized areas of recession due to the prior use of smokeless tobacco. Four periodontal pockets measuring 4-5 mm were noted on maxillary posterior teeth. Moderate supragingival and slight subgingival calculus and moderate stain accumulations were noted on his dentition.

Damage from methamphetamine use can include caries, periodontal disease, erosion, and fracturing and attrition from bruxism while using methamphetamine. This patient had damage in the form of caries, erosion, attrition and periodontal disease. Despite the great extent of damage to the teeth from the use of methamphetamine drugs, the main concern expressed about the cosmetic appearance of his mouth centered on the gingival recession created from periodontal disease and prior use of smokeless tobacco in addition to the supragingival calculus. While there were numerous areas of exposed dentin present, he was not experiencing dental pain. Treatment to correct these areas was not performed due to the financial barriers. Figures 1 and 2 represent the periodontal and dental charting completed during the initial assessment at the initial appointment.

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[FIGURE 2 OMITTED]

While he indicated that he occasionally clenched his teeth together, clinical signs of torus palatinus, bilateral cheek biting, attrition and abfraction indicated that the habit is more severe than he was aware. His mandibular anterior teeth exhibited moderate attrition as well as the lingual surfaces of the maxillary anterior teeth. Generalized moderate abfraction due to bruxism was evident elsewhere. Multiple teeth displayed demineralization and chipping of enamel from the use of methamphetamine, poor oral hygiene and the consumption of sweets. Erosion was also evident on several teeth as a result of the acidic nature of methamphetamine and consumption of high amounts of cranberry juice and Mountain Dew. Figures 3 and 4 portray the damage that occurred to his teeth as a result of bruxism, methamphetamine use, acid erosion from beverages, and poor oral hygiene.

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Health Conditions and Medications

Upon reviewing the medical history form, several health concerns were found. Those pertinent to the dental appointment included high blood pressure; a stroke one year prior; arthritis in his knees, ankles and hands; a history of hiatal hernia; Attention Deficit Disorder (ADD); mental and emotional impairment; and anxiety. The long-term debilitation from the stroke placed him on disability status. Within the following year, he developed high cholesterol. He had previously been affected by gastroesophageal reflux disease (GERD), which can allow gastric acid into the oral cavity. Gastric acid causes enamel erosion, most commonly on the posterior mandibular teeth. This individual was missing many posterior mandibular teeth, so he is less likely to develop acid erosion of enamel as a result of GERD.

At the initial appointment, he was taking Altace, atenolol and hydrochlorothiazide to control hypertension. He later added Zocor to treat hypercholesterolemia. Insomnia is a side effect of four medications he was taking. Ambien CR was taken as a temporary treatment for his insomnia. Adderall was taken for ADD. Ativan and Abilify were taken to suppress anxiety and depression. Percodan and Darvon were used to relieve pain from prior shoulder, knee and ankle injuries resulting from sporting events. A medication summary from his initial appointment including dental-related adverse effects and those experienced by this client are found in Table I. Several medications listed cause xerostomia. He counteracted this by drinking water frequently during the day. While some of the medications had the potential to cause hypotension, hypertension, bradycardia, tachycardia and respiratory depression, his vital signs were within normal limits at each appointment. An interesting adverse effect of Ativan is decreased hand-eye coordination. Dental providers should take note of this adverse effect due to its ability to interfere with proper brushing and flossing skills.
Table I. Medication Summary and Adverse Effects

Medication                Pertinent adverse         Adverse effects
                               effects            experienced by the
                                                          client

Altace               xerostomia, nausea,          xerostomia
                     vomiting

hydrochlorothiazide  sialadenitis, dizziness,     insomnia
                     restlessness, insomnia,
                     nausea, vomiting

atenolol             xerostomia, taste            xerostomia,
                     disturbance, taste           insomnia
                     loss, hypotension,
                     bradycardia, postural
                     hypotension, nausea,
                     vomiting, insomnia,
                     depression

Adderall             xerostomia, unpleasant       xerostomia,
                     taste, hyperactivity,        insomnia
                     restlessness, insomnia,
                     hypertension, tachycardia

Ativan               xerostomia, coated           xerostomia,
                     tongue, difficulty           coated
                     swallowing, gingival pain,   tongue,
                     increased salivation,        gingival pain
                     restlessness, bradycardia,   on #8-9,
                     tachycardia, hypertension,   restlessness
                     hypotension, respiratory
                     depression, interferes with
                     eye-hand coordination

Ambien CR            xerostomia, depression       xerostomia
Abilify              increased salivation,        insomnia
                     insomnia, depression,
                     nausea, vomiting,
                     dyspepsia

Percodan             xerostomia, increased        xerostomia
                     oral bleeding, hypotension,
                     bradycardia, tachycardia,
                     nausea, vomiting

Darvon               xerostomia, hypotension,     xerostomia
                     tachycardia, nausea,
                     vomiting


[FIGURE 5 OMITTED]

A family history reveals heart disease and diabetes mellitus. His risk factors for heart disease and stroke include high blood pressure and tobacco use; as mentioned before, he had suffered a stroke one year prior to his initial dental hygiene appointment. Even though he has not been diagnosed with diabetes mellitus, a family history indicates he is more likely to develop the condition. Dental hygienists are properly educated about the two-way connections between diabetes and periodontal disease. Education about the link between diabetes mellitus and periodontal disease should always be provided to a client with a persona history or family history of diabetes mellitus. Discussions centered on the link between heart attack and stroke as a result of periodontal infection should also occur with this client. Signs of periodontal disease found in his periodontium included bleeding, erythema, edema, blunted interdental papillae and bone loss. Bleeding was minimal, likely due to the vasoconstrictor effects from nicotine.

Treatment Procedures

The treatment for this client included a full-mouth series of radiographs, intraoral photos, selective use of the ultrasonic scaler on the mandibular anterior region, selective hand scaling to remove the remaining deposits, selective polishing, and application of a sodium fluoride gel. Fluoride varnish would also be ideal for any client with similar oral damage. The canous lesions and damage from smoking methamphetamine seen in Figures 2, 3 and 4 can be viewed radio-graphically in the full-mouth series in Figure 5.

The majority of his teeth exhibited generalized caries with multiple areas of exposed cementum. These conditions required the use of light scaling and root planing to avoid removing demineralized enamel and cementum. For this reason, the ultrasonic scaler was used only to remove supragingivat calculus and stain from the mandibular anterior teeth. Demin-eralized enamel can remineralize if they remain in contact with appropriate levels of fluoride; therefore, a prescription was written for fluoride dentifrice. Prescription fluoride dentifrices are also indicated for clients experiencing xerostomia. Xerostomia can affect methamphetamine users due to the drying effects of the drug as well as adverse reactions to prescription medication. During a follow-up appointment with this client, he expressed this product was easy to implement and used it daily.

While observing the client during treatment, the clinician noticed that he seemed very anxious and overly alert. The client reported that he was extremely self-conscious of the appearance of his teeth and concerned about receiving dental hygiene therapy for the first time in many years. During the appointments, he constantly moved his feet back and forth, rubbed his hands together or twirled his thumbs, and rocked when sitting upright. These changes in behavior may also be related to neurological damage from the prior use of methamphetamine, ADD, medication side effects, current use of tobacco, and high intake of sugar in his diet.

Oral health instructions for a current or prior methamphetamine user should always include discussion of acid erosion, nutritional analysis, and emphasis on the importance of daily plaque removal. Acid erosion of enamel may occur from the acidic nature of methamphetamine as well as dietary preferences for soda and juice. Even though this individual was attempting to counteract some of his negative habits with a healthier option of drinking juice instead of soda, it added equal if not more significant damage to his teeth from acid erosion of the enamel. The pH of soda is generally lower than that of juice, but so is its level of titratable acid. Titratable acidity is the amount of acid in a beverage available to erode enamel. Juices have more erosion potential than sodas because of their higher titratable acidity. (4) Enamel erosion can be minimized through the daily use of a dentifrice containing sodium fluoride. (5) While several types of dentifrices on the market contain fluoride, it is important to recommend one with sodium fluoride. These formulations are more effective in rehardening enamel previously softened by add challenges than ones containing sodium monofluorophosphate. (6)

Additional instructions to this client included modifying his brushing method and nutritional guidance with an emphasis on the negative impact of sugar intake and tobacco use on the oral cavity. A recare interval of four months was utilized to monitor his periodontal status as well as the demineralized enamel. Tobacco cessation was emphasized again at the next appointment with successful follow through by the client. He achieved success in tobacco cessation through immediate discontinuation of smoking replaced by short-term use of smokeless tobacco products. Within a few months, he had eliminated tobacco use from his lifestyle.

Current follow-up with this client indicated that he is very motivated to continue to maintain oral health. A relapse with tobacco occurred after his father was diagnosed with leukemia. He currently smokes five cigarettes a day and is interested in cessation methods. He is seeking treatment options to determine the best route of care for restoring his teeth while continuing to receive periodontal maintenance therapy infrequently. Financial barriers for restorative treatment continue; the most recent cost estimate for full-mouth restorative treatment was nearly $11,000. Working with this client has been heartbreaking and rewarding at the same time. His motivation to improve his oral health makes it an ideal fit for any dental hygienist who enjoys working with diversity. Seeing his genuine interest in his oral health makes it unimaginable to consider how he neglected his mouth during the binges of using methamphetamine, but that is the rollercoaster individuals with addictions face every day.

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References

(1.) National Institutes of Health. NIDA InfoFacts: Methamphetamine. Available at: drugabuse.gov/infofacts/methamphetamine.html. Accessed Apr. 8, 2011.

(2.) Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (OAS). Results from the 2009 National Survey on Drug Use and Health: national findings. Available at: www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf. Accessed Apr. 8, 2011.

(3.) Frese PA, Kunselman B, McClure EA, Shierling J. Methamphetamine: implications for the dental hygienist. Access. 2006; 20(9): 16-22.

(4.) JensdottirT, Holbrook P, Nauntofte B, et al. Immediate erosive potential of cola drinks and orange juices. J Dent Res. 2006; 85(3): 226-30.

(5.) Fowler CE, Gracia L, Edwards MI, et al. Inhibition of enamel erosion and promotion of lesion rehardening by fluoride: a white light interferometry and microindentation study. J Clin Dent. 2009; 20 (Special Issue).

(6.) Barlow AP, Sufi F, Mason SC. Evaluation of different fluoridated dentifrice formulation using an in situ erosion remineralization model. Journal of Clinical Dentistry 2009; 20(6): 178-85.

Mrs. Emily R. Holt, RDH, MHA, COA, is an assistant professor of dental hygiene and dental assisting at the University of Southern Indiana in Evansville, Indiana. Her scholarly activities include working with individuals with drug addictions, including methamphetamine addiction. She also practices dental hygiene at the office of or Dana Morris in Newburgh, Ind.

Sara M. Werner, LDH, B5, attended the University of Southern Indiana and graduated with a Bachelor of Science degree in dental hygiene in 2010. She is currently practicing dental hygiene in Lafayette, Ind., as well as providing oral health education to local schools.

By Emily Holt RDH, MHA, CDA, and Sara Werner, LDH, BS
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Title Annotation:chinical feature
Author:Holt, Emily; Werner, Sara
Publication:Access
Article Type:Clinical report
Geographic Code:1USA
Date:Apr 1, 2012
Words:2265
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