By Pamela J. Myers, RDH, CCHP
Dental Hygiene Coordinator
University of Texas Medical Branch, Correctional Managed Care
Chemical abuse is a serious national problem that has the potential to affect all of our lives. As dental hygienists, we may have already seen the effects of drug abuse in our offices. As healthcare professionals, it is essential that we become familiar with drug abuse and how it affects our patients health and our own lives.
Chemical dependency has many faces and takes many forms through the use of depressants, stimulants, hallucinogens and alcohol. The most commonly abused stimulants are caffeine and nicotine. The oral manifestations related to the use of these stimulants will not be covered in this article.
Instead, there are a number of Central Nervous System Stimulants (CNSSs) commonly abused by chemically-dependent individuals that include over-the-counter diet pills, prescribed amphetamines, street amphetamines, methamphetamines and cocaine.
The neighbor next door?
Studies indicate that approximately 10 percent of the general population are afflicted with some form of chemical dependency, while 16 to 24 percent of professionals in health-related fields have a substance abuse problem. It is likely you will treat one of these individuals. As statistics show, this patient may be your next door neighbor.
It is of utmost importance that we recognize chemical dependency and it's oral manifestations. We can use the information to reinforce and educate our patients and others as to the oral and systemic problems unique to the central nervous system stimulant abuser.
The neurochemical and clinical effects of cocaine and amphetamines are similar, but the two drugs are structurally dissimilar. The duration of the drug's effects are different:
Oral manifestations similar
Even though the duration of effects is different with CNS stimulants, the oral manifestations are similar to a point. Cocaine and methamphetamines cause xerostomia (dry mouth) because of the decrease in the salivary flow, which also contributes to an increased decay rate. The type of carious lesions seen in these individuals resembles "radiation decay. It is large, dark in color and appears at the cervical one third of the tooth at the gum line. There is some debate whether these drugs contribute to periodontal disease because of patient neglect or apathy, or whether the xerostomia and anorexia caused by the drugs are the predominant factors.
Cocaine also causes small vessel vasoconstriction which retards the healing process and therefore would be a factor in the progression of periodontal disease.
The anorexia caused by cocaine and amphetamines results in specific oral manifestations seen in malnourished individuals or in individuals with eating disorders. Angular cheilitis ("cracking" or inflammation at the corners of the mouth or lips), candidiasis or thrush and glossdynia (pain or a burning sensation of the tongue) are the three most common pathological conditions related to the anorexia. Necrotizing gingivitis has also been observed in these individuals as a result of poor diet and stress. Even though these abusers brush their teeth, they will still have halitosis: the ketotic odor resembles alcohol.
In their "high" state, abusers tend to brush their teeth very aggressively resulting in severe toothbrush abrasion and gingival laceration. While in a euphoric state, these individuals brux constantly. This severe bruxism can lead to TMJ syndrome, myofacial pain dysfunction, incisal and occlusal wear/attrition and bilateral massetter muscle hypertrophy. If parotid glad enlargement induced by alcohol and bilateral massetter muscle hypertrophy occur in the same individual, his face takes on a chipmunk appearance. Although, there are a number of oral manifestations common with abuse of either drug. Individuals dependent on cocaine exhibit specific manifestations inherent with their drug of choice.
Cocaine use on the rise
Cocaine was used by the dental profession in the late 1880s as a local anesthetic. This anesthetic property contributes to the problems associated with serious decay because the individual feels no pain. Cocaine's use as a recreational drug has enhanced and reached epidemic proportions, with more than 22 million Americans who have tried or abused the drug.
With this increasing use, dental hygiene clinicians will see more oral manifestations of cocaine abuse than amphetamine abuse. The most unusual pathology appears as a dark, almost black, soft palate occurring in those individuals abusing "crack", which is a crystallized form of cocaine that is smoked. Crack is made by combining refined cocaine, ammonia liquid, cold water and baking soda. It is inexpensive compared to most street drugs and is more commonly used. The high lasts only a few minutes, thus contributing to the frequent use.
Cocaine, in its powdered form, is usually inhaled or "snorted." Abusers commonly draw the drug into their nasopharynx and from there into the oral cavity. Prolonged use of the drug in this manner results in perforation of the nasal septum. An unusual form of dental erosion occurs when the cocaine is present in the oral cavity for extended periods because of nasal insufflation. This coronal destruction is because of the process by which cocaine is refined.
Cocaine is refined by treating cocoa leaves with an organic solvent and then with hydrochloric acid, which extracts the pharmaceutically active water-soluble salt. Pure cocaine hydrochloride powder has a pH of 4.5. When mixed with saliva this becomes a powerful acid capable of dissolving calcium phosphate hydroxyapatite, the predominant mineral found in dental enamel and dentin.
Many abusers who have experienced a perforated septum then begin to rub the drug directly onto the gingivae causing the desquamation of the epithelium, as well as eroding the enamel.
Other oral pathological conditions have been observed in individuals dependent on cocaine. Three common conditions are gingival hyperplasia, erosive lichen planus and herpetic gingivostomatitis. Ecchymosis of the oral mucous membranes, which appears as a bruised or hemorrhagic area, is due to allergic thrombocytopenia. It has been reported in cocaine abusers and is a result of an abnormal decrease in blood platelets. Gross scaling or curettage procedures performed at this time on these individuals would result in abnormal bleeding.
Leukodemia, abnormally retained sponge-like epithelial cells and hyperparakeratosis, a disorder appearing as a thick fur-like area on the dorsum surface of the tongue, which affects the horny layer of the epidermis, are also resultant pathology related to cocaine use.
Know systemic conditions, too
Recognizing the oral manifestations of chemical dependency is important to the clinician as well as recognition of the accompanying systemic problems that could affect the delivery of dental care.
The patient we may be providing treatment to may have recently used CNSSs and could experience life-threatening complications such as cardiac arrest, a hypertensive crisis or a cerebrovascular accident. Those individuals who have recently used cocaine or amphetamines may be hyperkinetic, hypertensive, or may experience tachycardia or tachypenia. The introduction of any vasoconstrictor at this time could be fatal.
Both amphetamines and cocaine may be injected and any individual with a history of IV drug use should be evaluated by his physician for organic valvular heart disease. When the non-sterile needle enters the vein the contaminated blood is carried to the heart and may eventually damage the tricuspid valve, which lies between the right atrium and the right ventricle. This places these individuals at risk for developing SBE (subacute bacterial endocarditis) after an invasive dental procedure. If the individual has also abused alcohol, the combination of the cocaine and alcohol may result in the patient being immunocompromised.
As dental health educators, we should consider the advice from the Partnership for a Drug-Free America and then pass it on.