Escolar Documentos
Profissional Documentos
Cultura Documentos
onmedicinal or illicit
N
D
A B S T R A C T
A
methamphetamine J
A
N
CON
IO
public health concern owing caries among methamphetamine users. The authors
T
T
A
investigated the prevalence of dental disease and asso- N
I
to the drug’s high prevalence A
U
IN
G ED
U
C
Dr. Brown is the dental director, Programs and Development, San Francisco General Dental Department, Native American Health Center, San Francisco; and
assistant clinical professor, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco.
Dr. Krishnan was a research assistant, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, when this study was
conducted. She now lives in Bangalore, India.
Dr. Hursh is the clinical dental director, San Francisco General Dental Department, Native American Health Center, San Francisco; and an assistant clinical
professor, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco.
Ms. Yu is a statistician, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco.
Dr. Johnson was a student, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, when this study was conducted.
He now is a pediatric dentist at Smile Island, Rocklin, Calif.
Dr. Page is a professor in residence, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco.
Dr. Shiboski is a professor of oral medicine, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, Box 0422, Room
S612, 513 Parnassus Ave., San Francisco, Calif. 94143-0422, e-mail caroline.shiboski@ucsf.edu. Address reprint requests to Dr. Shiboski.
in the United States.3,4 The percentages of U.S. mouth” suggests. Authors of a 2010 systematic
admissions to substance abuse treatment serv- review of methamphetamine use and dental dis-
ices for primary methamphetamine or ampheta- ease emphasized the need for more definitive
mine use more than doubled from 1996 to 2007, epidemiologic studies.19 Therefore, we conducted
from 3.3 percent to 7.5 percent. In California, an exploratory pilot study to evaluate dental
methamphetamine-related admissions disease prevalence and patterns, as well as
increased by 363 percent from 1992 to 2005.5 dental caries risk factors, among injection-drug
Investigators have uncovered an association users (IDUs), comparing methamphetamine and
between illicit drug use and poor oral hygiene, heroin users. The caries risk factors explored
high sugar intake, alcohol use and tobacco use.6-9 included dietary practices, signs and symptoms
Dependence on drugs also is associated with of salivary hypofunction, and measures of oral
severe social, financial and health conse- hygiene. This pilot study also was meant to
quences.10 One of the many reported adverse assess the feasibility of recruiting a population
health effects noted with long-term methamphet- of IDUs and to determine how readily these
amine use is severe dental caries, widely referred users can be categorized according to the types
to as “meth mouth” in the scientific literature of drugs they use.
and in the press.11 First reported by Shaner12 in
1992, meth mouth is described as rampant METHODS
dental caries in a pattern specifically on buccal Study population. We recruited participants for
and lingual surfaces and involving widespread this cross-sectional pilot oral health study by
destruction of coronal tooth structure, often drawing a convenience sample from a larger
appearing as residual root tips. Although this ongoing cohort study of young adult IDUs in a
atypical caries pattern in adults is speculated to clinic in the Tenderloin district in San Francisco.
be specific to methamphetamine use, it also is Investigators at the University of California, San
associated with hyposalivation secondary to radi- Francisco (UCSF), designed this larger parent
ation treatment and was first reported as being cohort, called the U Find Out study, part 1 (UFO-
associated with prolonged heroin use and in poly- 1), to screen young adult IDUs for participation in
drug users.7,13-15 In addition to this atypical caries prospective epidemiologic studies regarding
pattern, bruxism, attrition and trismus have human immunodeficiency virus (HIV) and hepa-
been reported among drug users, including titis B virus (HBV) and hepatitis C virus (HCV)
methamphetamine users.16 infections; 1,445 participants are enrolled in it.20
The etiology of dental caries secondary to pro- Inclusion criteria for UFO-1 included the fol-
longed drug use has been attributed to salivary lowing: age from 18 to 29 years at enrollment,
hypofunction, poor oral hygiene and high- self-report of use of an illicit injection drug in the
frequency consumption of refined carbohy- preceding month, ability to speak English and
drates.15 Methamphetamine use is thought to recruitment by means of street-outreach
stimulate inhibitory α2-adrenergic receptors via methods. Participants who tested negatively for
the central nervous system, thus inhibiting HCV, HBV and HIV have been followed up every
unstimulated salivary flow.17 However, although three months as part of a substudy called U Find
multiple clinical case reports and public aware- Out, part 3a.21 We recruited participants for our
ness messages of meth mouth have been pub- oral health pilot study from participants in the
lished, few investigators have conducted epi- UFO-3a study who were reporting for follow-up
demiologic studies to explore the relationship visits for that study across a seven-week period in
between methamphetamine use and clinical the spring of 2007. Participants were recruited
manifestation of secondary, atypical dental and enrolled during a weekly three-hour session
caries or tooth-loss patterns in a population. in our Tenderloin district clinic. Eligibility criteria
The results of observational studies have shown were the same as those for participants in the
higher caries rates in drug users than in non-
drug users and higher tooth-loss rates in ABBREVIATION KEY. BZD: Benzodiazepine. DMFS:
methamphetamine users than in nondrug Decayed-missing-filled surfaces. HBV: Hepatitis B
users.7,18 Shetty and colleagues18 reported a sta- virus. HCV: Hepatitis C virus. HIV: Human immuno-
deficiency virus. IDUs: Injection-drug users.
tistically significant association of missing teeth
NHANES: National Health and Nutrition Exami-
with the use of injected (as compared with nation Survey. NSDUH: National Survey on Drug
smoked) methamphetamine. It is still not clear, Use and Health. S-OHI: Simplified Oral Hygiene
however, whether a high caries rate is a conse- Index. UCSF: University of California, San Fran-
quence of any injection-drug use or is specific to cisco. UFO-1: U Find Out study, part 1. UFO-3a:
methamphetamine use, as the term “meth U Find Out study, part 3a.
We used contingency table analyses and the 997). The main difference between the two
Fisher exact test to compare specific drug-use groups with respect to drug use was a much
characteristics, dietary practices, dry mouth higher proportion of use of speedball (heroin
symptoms, measures of oral hygiene, reported and cocaine mixed together) (63 percent) and
use of dental care in the previous year, catego- benzodiazepine (BZD) pills (61 percent) among
rized DMFS index scores, number of decayed heroin users compared with usage rates for
surfaces and residual roots between meth and those drugs of 29 and 13 percent, respectively,
heroin users. We computed the median and among meth users (P = .02 and P < .01, respec-
range of the DMFS index, the number of tively). All heroin users and 94 percent of meth
decayed surfaces, the number of residual roots users were current tobacco smokers, with 63
and S-OHI scores, and we also compared partici- percent of those in the Heroin group and 44 per-
pants in the Meth and Heroin groups with cent of those in the Meth group smoking at least
respect to these variables by using a Mann- one pack of cigarettes per day. One-half of the
Whitney rank-sum test. participants reported having used injection
drugs for at least eight years and reported
RESULTS having injected drugs, on average, two to three
From April 17, 2007, through June 5, 2007, as times per day.
part of seven three-hour sessions, we recruited About one-half of meth users reported
61 participants at our clinic in the Tenderloin drinking two or more glasses of fruit juice per
district in San Francisco. We excluded from the day and one-third (29 percent) reported drinking
final analysis three participants who did not five or more nondiet soft drinks per day, com-
complete the parent study follow-up question- pared with 24 percent and 5 percent, respec-
naire and, therefore, did not provide complete tively, of the heroin users (Table 3, page 998)
data regarding their drug-use behavior. Among (P = .06 and P = .07, respectively). More than 40
the 58 participants with complete data, 17 (29 percent of participants in both groups reported
percent) reported methamphetamine to be their having only one full meal (such as breakfast,
most commonly used injection drug and 41 (71 lunch or dinner) or less per day. Heroin users
percent) reported predominant heroin use in the reported snacking more frequently, with a snack
preceding month. This is consistent with the being defined as a small amount of food con-
pattern of drug use reported by participants in sumed outside of regular meals; 40 percent of
the UFO-3a study, in which 31 percent reported heroin users snacked six or more times per day
using methamphetamine most days.25 The compared with 24 percent of meth users. One-
majority of participants among both meth and third of meth users reported having “cotton
heroin users were male (76 and 66 percent, mouth” often or all the time, and 35 percent said
respectively), were white (53 and 88 percent) they needed to sip water to help them swallow
and had graduated from high school (59 and 44 their food (Table 3). However, we found no statis-
percent) (Table 1). The participants ranged in tically significant difference with respect to xero-
age from 18 to 36 years, with 76 percent and 78 stomia or clinician-observed signs of oral cavity
percent being younger than 30 years among dryness between the two groups.
meth and heroin users, respectively. More than About one-half of the participants in each
one-third in either group reported not having group reported never or only occasionally
been housed the previous night. There was no brushing their teeth (Table 3). Nearly one-third
significant difference in sociodemographic char- (28 percent) of heroin users had poor oral
acteristics between users in the Meth and hygiene (with an S-OHI score higher than 3)
Heroin groups except with respect to race, with compared with none in the Meth group, and the
a higher proportion of whites among the heroin association between S-OHI score and type of
users. A comparison of sociodemographic vari- drug predominantly used was statistically sig-
ables between the present subsample and the nificant (P = .04). However, the median S-OHI
larger cohort revealed no statistically signifi- scores were 2.08 among meth users and 2.33
cant difference with respect to sex (P = .78), race among heroin users, and the results of a non-
(P = .58) or education (P = .38), suggesting that parametric test (rank-sum) did not reveal a sta-
our subsample was representative of the larger tistically significant difference in the S-OHI
cohort. scores between the two groups (P = .37). Thus,
A large proportion of participants in both although a significantly higher proportion of
Meth and Heroin groups reported using a wide heroin users were categorized as having poor
variety of both other injection and noninjection oral hygiene, the median S-OHI score did not
drug types in the past month (Table 2, page differ significantly between the two groups.
TABLE 2
TABLE 3
their examination and disclosure of their oral Disclosure. None of the authors reported any disclosures.
health status; this was despite the participants’ The study described in this article was supported by grant R03
high rates of caries and the presence of frac- DE14939 from the National Institute of Dental and Craniofacial
tured teeth and residual roots, and despite the Research and grant R01 DA016017 from the National Institute on
Drug Abuse, National Institutes of Health, Bethesda, Md.
fact that each participant was given a voucher
to receive an examination, a dental prophylaxis The authors acknowledge the ongoing participation of all the par-
ticipants in the U Find Out study, University of California, San
and urgent care if needed. This suggests that Francisco, whose involvement continues to help provide important
active IDUs’ perceived dental care need may not information to public health practitioners and researchers. They
equate with their actual oral health status. It express sincere appreciation to Jennifer Evans, Erin Aying, Anuhya
Uppula, Nicholas Ching, Rithika Mathias and Karina Alcala for their
also alludes to the challenges faced by public help with this project.
health professionals and community leaders in
1. U.S. Department of Health and Human Services, Substance
developing strategies to prevent and manage Abuse and Mental Health Services Administration, Office of Applied
dental disease effectively in this population Studies. Results from the 2007 National Survey on Drug Use and
through effective preventive strategies. Also, cli- Health: National Findings. Rockville, Md.: U.S. Department of
Health and Human Services, Substance Abuse and Mental Health
nicians should consider all types of drug use Services Administration, Office of Applied Studies; 2008. DHHS pub-
when they suspect that a patient has meth lication (SMA) 08-4343.
mouth and should probe previous and present 2. U.S. Department of Health and Human Services, Substance
Abuse and Mental Health Services Administration, Office of Applied
substance use with their patients. Studies. Results from the 2009 National Survey on Drug Use and
Health. Volume I: Summary of National Findings. Rockville, Md.:
CONCLUSION U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Office of Applied
In this study, we were successful in recruiting Studies; 2010. DHHS publication (SMA) 10-4856.
active and long-term users of methampheta- 3. Johnston LD. Monitoring the Future: National Survey Results
on Drug Use, 1975-2007. Volume 2: College Students and Adults
mine and heroin for the purpose of investigating Ages 19-45. Bethesda, Md.: National Institute on Drug Abuse; 2008.
oral disease. It is the first study to our knowl- NIH publication 08-6418B:319.
edge to involve the use of established oral 4. Johnston LD. Monitoring the Future: National Results on Ado-
lescent Drug Use—Overview of Key Findings, 2008. Bethesda, Md.:
health clinical indexes by which trained dental National Institute on Drug Abuse, U.S. Department of Health and
professionals, using calibrated technique, could Human Services, National Institutes of Health; 2009. NIH publica-
tion 09-7401:1-74.
measure dental disease prevalence and covari- 5. U.S. Department of Health and Human Services, Substance
ates in such a cohort. Furthermore, it provides Abuse and Mental Health Services Administration, Office of Applied
valuable information regarding the pattern and Studies. Treatment Episode Data Set (TEDS) Highlights—2007:
National Admissions to Substance Abuse Treatment Services.
variety of drug use among young adult IDUs in Rockville, Md.: U.S. Department of Health and Human Services,
an urban setting. Substance Abuse and Mental Health Services Administration, Office
Lessons learned from this exploratory study of Applied Studies; 2009. DASIS series S-45, DHHS publication
(SMA) 09-4360. www.samhsa.gov/data/TEDS2k7highlights/
suggest that a large sample size, a more elabo- TEDSHigh2k7.pdf. Accessed July 12, 2012.
rate sampling strategy and a study design such 6. Robinson PG, Acquah S, Gibson B. Drug users: oral health-
related attitudes and behaviours. Br Dent J 2005;198(4):219-224.
as cohort-control, in which participants are 7. Reece AS. Dentition of addiction in Queensland: poor dental
recruited according to their exposure or risk status and major contributing drugs. Aust Dent J 2007;52(2):144-149.
factor, may be needed in future research to 8. Titsas A, Ferguson MM. Impact of opioid use on dentistry. Aust
Dent J 2002;47(2):94-98.
explore the association between any specific 9. Sandler NA. Patients who abuse drugs. Oral Surg Oral Med
drug used and dental disease. This may require Oral Pathol Oral Radiol Endod 2001;91(1):12-14.
consideration of patients living in rural settings, 10. Charnock S, Owen S, Brookes V, Williams M. A community
based programme to improve access to dental services for drug users.
where methamphetamine use may be more Br Dent J 2004;196(7):385-388.
prevalent or may be used exclusively. Mean- 11. Davey M. Grisly effect of one drug: ‘meth mouth.’ The New York
Times June 11, 2005. www.nytimes.com/2005/06/11/national/
while, given the high level of dental disease 11meth.html?pagewanted=all. Accessed July 12, 2012.
observed in this population of IDUs, one next 12. Shaner JW. Caries associated with methamphetamine abuse.
step may be to explore the feasibility and effec- J Mich Dent Assoc 2002;84(9):42-47.
13. Kielbassa AM, Hinkelbein W, Hellwig E, Meyer-Luckel H.
tiveness of low-intensity preventive measures Radiation-related damage to dentition. Lancet Oncol 2006;7(4):
for this population (for example, distribution of 326-335.
chlorhexidine rinses or xylitol gum or applica- 14. Keene HJ, Daly T, Brown LR, et al. Dental caries and Strepto-
coccus mutans prevalence in cancer patients with irradiation-
tion of fluoride varnishes). Furthermore, pro- induced xerostomia: 1-13 years after radiotherapy. Caries Res
viding oral health education and low-intensity 1981;15(5):416-427.
15. Colon PG Jr. Dental disease in the narcotic addict. Oral Surg
intervention at sites where drug users typically Oral Med Oral Pathol 1972;33(6):905-910.
receive public health services and enlisting the 16. McGrath C, Chan B. Oral health sensations associated with
help of outreach workers in these settings may illicit drug abuse. Br Dent J 2005;198(3):159-162.
17. Saini T, Edwards PC, Kimmes NS, Carroll LR, Shaner JW,
help encourage disenfranchised drug users to Dowd FJ. Etiology of xerostomia and dental caries among metham-
accept selected strategies to prevent dental phetamine abusers. Oral Health Prev Dent 2005;3(3):189-195.
disease. ■ 18. Shetty V, Mooney LJ, Zigler CM, Belin TR, Murphy D, Rawson
R. The relationship between methamphetamine use and increased to 64). Bethesda, Md.; 2010. www.nidcr.nih.gov/DataStatistics/
dental disease. JADA 2010;141(3):307-318. FindDataByTopic/DentalCaries/DentalCariesAdults20to64.htm.
19. Marshall BD, Werb D. Health outcomes associated with Accessed July 12, 2012.
methamphetamine use among young people: a systematic review. 27. Centers for Disease Control and Prevention. Vital Signs: Cur-
Addiction 2010;105(6):991-1002. rent Cigarette Smoking Among Adults Aged ≥ 18 Years—United
20. Inglez-Dias A, Hahn JA, Lum PJ, Evans J, Davidson P, Page- States, 2005–2010. MMWR Morbid Mortal Wkly Rep 2011;60(33):
Shafer K. Trends in methamphetamine use in young injection drug 1207-1212.
users in San Francisco from 1998 to 2004: the UFO Study. Drug 28. Lambert D, Gale JA, Hartley D. Substance abuse by youth and
Alcohol Rev 2008;27(3):286-291. young adults in rural America. J Rural Health 2008;24(3):221-228.
21. Hahn JA, Page-Shafer K, Lum PJ, Ochoa K, Moss AR. Hepa- 29. Wilkins C, Sweetsur P, Griffiths R. Recent trends in pharma-
titis C virus infection and needle exchange use among young injec- ceutical drug use among frequent injecting drug users, frequent
tion drug users in San Francisco. Hepatology 2001;34(1):180-187. methamphetamine users and frequent ecstasy users in New Zealand,
22. Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia 2006-2009. Drug Alcohol Rev 2011;30(3):255-263.
and objective measures of salivary gland performance. JADA 30. Tan KR, Brown M, Labouebe G, et al. Neural bases for addic-
1987;115(4):581-584. tive properties of benzodiazepines. Nature 2010;463(7282):769-774.
23. Klein H, Palmer CE, Knutson JW. Studies on dental caries, 31. Chalmers J, Bradford D, Jones C. The effect of methampheta-
part I: dental status and dental needs of elementary school children. mine and heroin price on polydrug use: a behavioural economics
Public Health Rep 1938;53:751-765. analysis in Sydney, Australia (published online ahead of print July 8,
24. Greene JC, Vermillion JR. The Simplified Oral Hygiene Index. 2010). Int J Drug Policy 2010;21(5):381-389. doi:10.1016/
JADA 1964;68:7-13. j.drugpo.2010.06.002.
25. Evans JL, Hahn JA, Lum PJ, Stein ES, Page K. Predictors of 32. Laslett AM, Dietze P, Dwyer R. The oral health of street-
injection drug use cessation and relapse in a prospective cohort of recruited injecting drug users: prevalence and correlates of problems.
young injection drug users in San Francisco, CA (UFO Study) (pub- Addiction 2008;103(11):1821-1825.
lished online ahead of print Jan. 31, 2009). Drug Alcohol Depend 33. Robbins JL, Wenger L, Lorvick J, Shiboski C, Kral AH. Health
2009;101(3):152-157. doi:10.1016/j.drugalcdep.2008.12.007. and oral health care needs and health care-seeking behavior among
26. National Institutes of Health, National Institute of Dental and homeless injection drug users in San Francisco. J Urban Health
Craniofacial Research. Dental Caries (Tooth Decay) in Adults (Age 20 2010;87(6):920-930.