Aesthetic Reconstruction of “Meth Mouth”

Due to the rise in use of methamphetamine (meth) in the United States, dental professionals should be aware of the effects of this dangerous recreational drug and treatment considerations for these drug users.1
Methamphetamine is not only a potent central nervous system (CNS) stimulant that can cause permanent brain damage, but its use is associated with severe oral health problems. It is a Schedule II drug, and because it is a CNS stimulant, it increases the heart rate, blood pressure, body temperature, and rate of breathing; it also dilates the pupils and produces euphoria, increased alertness, a sense of increased energy, and tremors.2
Domestic methamphetamine production, trafficking, and abuse are concentrated primarily in the western and southwestern regions of the United States. The cities in these regions encountering the most significant problems with abuse include Los Angeles, Phoenix, San Diego, San Francisco, and, to a lesser degree, Dallas, Denver, and Seattle. Much of the clandestine laboratory activity remains centered in California, where the methamphetamine problem is most acute. Methamphetamine also is available consistently in wholesale quantities in some cities in the Midwest and the South.2
Traditionally, methamphetamine users have suffered the same addiction cycle and withdrawal reactions as those suffered by crack cocaine users. Both drugs, after prolonged use, lead to binging (consuming the drug continuously for up to 3 days without sleep). The user then is driven into severe depression, followed by worsening paranoia, belligerence, and aggression, a period known as tweaking. Finally, the user collapses from exhaustion, only to awaken days later to begin the cycle again. However, the new ephedrine-based methamphetamine has a usage pattern unlike that of traditional methamphetamine or crack cocaine. Several times more potent than its other forms, this form of methamphetamine produces a reaction far more severe than even crack cocaine, with sleepless binges that last up to 15 days and end with intolerable crashes.2
The most frequent method of methamphetamine use is injection. The drug may also be inhaled (snorted), smoked, and even added to drinks such as coffee. Chronic, high-dose meth abusers are generally undernourished with gaunt appearance, poor hygiene, and teeth with extensive caries. These individuals inject methamphetamine every 2 to 3 hours, often as much as 1,000 mg each time. The price of methamphetamine ranges from $50 to $150 per gram. Traditionally, methamphetamine use has been most pronounced among males between the ages of 19 and 40. Methamphetamine use is reportedly increasing among college students and young professionals involved in the club scene or participating in rave parties, where the drug has emerged among a battery of party drugs that often include LSD, marijuana, Ketamine, and alcohol.2
The illicit manufacture of methamphetamine can be accomplished in a variety of ways, but it is produced most commonly by using either of two primary synthesis methods. The fundamental difference between the two methods is in the use of precursor chemicals. The first method requires the use of ephedrine or pseudoephedrine (found in allergy and cold medicines). The second method uses phenyl-2-propanone. However, ephedrine/pseudoephedrine accounted for 89% of all meth laboratory seizures reported to the Drug Enforcement Administration (DEA).2

Figure 1. Pretreatment smile.

Rampant caries that resembles early childhood caries has been described in users of this drug and is being referred to as meth mouth (Figure 1). The rampant caries associated with methamphetamine use is attributed to the acidic nature of the drug, the drugs xerostomic effect, its propensity to cause cravings for high-calorie carbonated beverages, associated tooth grinding and clenching, and its long duration of action, which leads to extended periods of poor oral hygiene.3-5 Further, the ADA encourages dental professionals to be aware that methamphetamine use is on the rise in the United States. The allure of this drug is that it is cheap and easy to make, and the euphoria lasts much longer than crack cocaine. Dental professionals are in a position to help with identification and aid for those who have become addicted to methamphetamine. Because of the obvious visual presentation known as meth mouth, dentists can easily identify abusers and help them not only with their dental problems, but help refer them to a substance rehabilitation facility.1
As described by the Meth Awareness and Prevention Project,6 lithium, muriatic and sulfuric acid, ether, red phosphorus, and lye are key ingredients in meth manufacturing, and all are corrosive and can cause skin burns. When a person smokes meth-amphetamine, these substances are heated and vaporized, and the vapors are swirled throughout the users mouth. The vapors irritate and burn the mucosa and attached gingiva, creating lesions that can become infected. Snorting the drug draws the caustic substances into the nasal passages, draining into the throat and the oral cavity and bathing the teeth in acidic fluid. Injecting the drug does not appear to be associated with any systemic effect on oral health, however, as already noted, the long duration of action can lead to poor personal hygiene, which typically includes dental hygiene.
A disturbing statistic from the 2003 National Survey on Drug Use and Health7 indicates that 12.3 million Americans age 12 and older had tried methamphetamine at least once (5.2% of the population). The majority of these users are 18 to 34 years old.

Figure 2. Pretreatment right lateral view.	Figure 3. Pretreatment left lateral view.

Multiple signs and symptoms suggest a diagnosis of methamphetamine use; among them are a distinctive pattern of decay on the buccal smooth surface of all teeth and the interproximal surfaces of the anterior teeth (Figures 2 and 3). In addition, a malnourished appearance and accelerated caries without an identifiable risk factor are signs usually associated with heavy meth use.
According to the ADA, specific actions should be taken if the practitioner suspects meth use:

(1) Complete a comprehensive oral examination that includes a thorough dental and medical history.
(2) Express concern re-garding the dental findings.8
(3) If the patient is receptive to a medical consult, have the phone number of a local physician, clinic, or substance abuse rehabilitation facility available, and be familiar with its protocol so the patient can be told what to expect.8
(4) Use preventive measures such as topical fluorides.
(5) Encourage consumption of water rather than sugar-containing carbonated beverages.
(6) Be cautious when administering local anesthetics, sedatives, general anesthesia, nitrous oxide, or prescribing narcotics.
(7) Take the opportunity to educate your patients about the risks associated with methamphetamine or other illicit drug use.9,10

Care should be taken when developing a treatment plan for users of methamphetamine. After the examination, the consultation with the patient should include an open discussion about drug use. If the patient admits or the practitioner suspects the patient is still using the drug, a treatment plan that stresses prevention is probably more prudent. If the patient is currently a non-user and (ideally) has been through a rehabilitation program, a more comprehensive treatment plan can be developed. However, it is recommended that a signed consent form be obtained from the patient in which the patient acknowledges an understanding of the ill-effects of future meth use on restorative dental procedures.
Patients who have successfully completed a drug rehabilitation program often are looking for a new start in life. However, if they are living with the discomfort and distressing, unaesthetic appearance that is associated with meth mouth, it can be difficult to return to a normal life. It is relatively easy for practitioners to relieve a patients discomfort, and restoring someones smile is enormously beneficial to improving self-esteem and a persons capacity to succeed in todays society, which places importance on personal appearance.
The following case report describes the aesthetic dental treatment of a patient with meth mouth.

CASE REPORT

Figure 4. Pretreatment occlusal view of the maxillary arch.	Figure 5. S.M.I.L.E.S. evaluation.

A 22-year-old male with a history of methamphetamine use was referred for an examination. A clinical and radiographic evaluation revealed multiple carious teeth. Several teeth had carious lesions that extended into the pulp chamber. Teeth Nos. 2 and 15 were severely compromised and were deemed nonrestorable (Figure 4). The periodontal evaluation indicated generalized soft-tissue inflammation with widespread bleeding following probing, heavy supragingival calculus deposits, and heavy stain. A neuromuscular evaluation and occlusal analysis revealed no abnormalities, with the patient reporting that he had no TMJ/myofacial pain.
After completing the oral examination, a S.M.I.L.E.S. (Figure 5) evaluation was completed, photographs were taken, and maxillary and mandibular alginate impressions were made for fabrication of study models. An interview revealed that the patient had been a methamphetamine user for several years as a teenager and had successfully gone through a drug intervention program 2 years ago. The patient stated that he no longer used any recreational drugs, but that he was very unhappy with his appearance and avoided smiling. The patient reported minimal oral discomfort (primarily generalized sensitivity to temperature changes).
Endodontic therapy was completed on teeth Nos. 6, 7, 10, and 11. A combination of 4 Seasons Direct Esthetic Composite System (Ivoclar Vivadent) and Clearfil Photo Core (Kuraray Dental) was used as build-up material following the placement of bonded translucent posts (Luscent Anchors [Dentatus]). The posts and build-up materials were chosen for their translucency, since the treatment plan for teeth Nos. 6, 7, 10, and 11 called for all-ceramic restorations (IPS Empress [Ivoclar Vivadent]). As for all of the all-ceramic systems, the presence of a metallic post and core is not advisable because of the shadow effect or grayness of the substructure that results after cementation. Caries removal and the subsequent buildup immediately improved the patients appearance.
Additional treatment completed prior to preparation of the teeth for all-ceramic restorations included maxillary and mandibular periodontal debridement with anesthesia using a combination of micro-ultrasonics and hand instruments, extraction of teeth Nos. 2, 15, and 16, endodontic therapy and a full-coverage restoration for tooth No. 31, and composite restorations on teeth Nos. 3, 5, 12, 14, and 22 to 27 using 4 Seasons. According to the manufacturer, 4 Seasons dentin shades were developed with a more opaque (7.4% to 7.9%) saturated chroma to support the basic color of the tooth structure from within; in addition, the enamel shades are produced within a tight tolerance of higher translucency (13.2% to 14.2%) to provide a natural depth to the restoration and diffuse the dentinal substrate. This combination of calibrated translucencies and tight tolerances ensures consistent color matching.11

Figure 6. Cen-Tech digital caliper.	Figure 7. Golden proportions.
Figure 8. Cosmetic checklist.	Figure 9. Symmetry Facial Plane Relator.

At this point, maxillary and mandibular alginate impressions were made for fabrication of models to be used for development of a diagnostic wax-up for ceramic restorations for teeth Nos. 6 through 11. The widths of the maxillary central incisors were recorded using digital calipers (Cen-Tech), and calculations were made to determine the golden proportions (ie, a width-length ratio of approximately 77%; Figure 6). The principles of golden proportion suggest that there is an ideal, mathematical ratio (1.6:1:0.6) among the apparent (rather than the actual) widths of the central incisors, lateral incisors, and canines when they are viewed from the facial aspect. The discrepancy between the apparent and actual widths is explained by the positioning of these teeth along the curve of the arch (Figure 7). Most authors recommend creating harmony and balance by evaluation of provisional restorations and performing needed adjustments rather than mathematical formulae. The teeth must display a sense of proportion, and the dominance of the central incisors must be readily apparent.12
Following the principles listed in Figure 8, teeth Nos. 6 to 11 were prepared. A photograph of the Symmetry Facial Plane Relator (SFPR [CLINICIANS CHOICE]; Figure 9) was taken to aide the dental laboratory technician. The SFPR ensures that the patients facial midline and dental midline coincide. According to the manufacturer, SFPR records an accurate bite registration and the exact position of the desired midline in relation to a horizontal plane. This is quickly accomplished (in less than 1 minute), and the measurements can be easily and accurately communicated to the laboratory. In addition, photographs of the preparation shade (stumpf shade), prescribed shade (if matching existing teeth or restorations), and provisional restorations are an important communication tool for a successful laboratory outcome.

Figure 10. Provisional restorations.

Provisional restorations were fabricated using a poly-vinyl stent fabricated from the wax-up. Exacta Temp Xtra (EXACTA) was used as the provisional material (Figure 10). It is a self-curing crown and bridge resin for the fabrication of temporary dental restorations. It is nonirritating to the gingival tissues and is available in shades A1, A2, A3, A3.5, B1, and Bleach. TempBond Clear (Kerr) was used as a temporary cement. It is light-cured and sets to a firm, rubbery consistency that allows easy cleanup. Its translucency eliminates the possibility of the lighthouse effect. This can occur when an opaque white cement is used under a translucent material, and the white shows through the temporary or final restoration. Adjustments were made to the provisional restorations, and all changes including the desired width and length dimensions for the anterior teeth were communicated to the laboratory with a diagram.
The patient returned in a few weeks for delivery of the final restorations. Teeth Nos. 6, 7, 10, and 11 were restored with full-coverage crowns, and teeth Nos. 8 and 9 were restored with veneers. All restorations were IPS Empress and were checked for marginal fit and aesthetics. IPS Empress is an all-ceramic and metal-free restorative material that provides a more aesthetic alternative to the traditional metallic post and core restorations. The utilization of bonded ceramic restorative materials is intended to re-establish function, shape, and color (hue, value, and chroma), while providing natural light transmission and the strength of natural dentition. IPS Empress provides high translucency (natural appearance) combined with increased durability and good wear compatibility. Also, there is the benefit of excellent margin adaptation.13

Figure 11. Removal of provisional restorations using rubber dam.

After the patient was anesthetized, a rubber dam was placed to isolate all maxillary anterior teeth. Each provisional restoration was sectioned, with care taken to avoid altering the tooth preparations (Figure 11). The provisional restorations were then gently removed, and hydrogen peroxide was applied to the teeth and gingiva to help remove debris that accumulated over the previous few weeks. Consepsis (Ultradent) was then applied and rinsed from the prepared tooth surfaces. Consepsis is an all-purpose cleaning/disinfecting solution that can be used prior to crown cementation, luting, and direct restorative placement. Consepsis solution is a 2.0% chlorhexidine gluconate solution with a pH of 6.0. It helps eliminate micro-organisms in the dentinal tubules and minimize postoperative pulpitis and sensitivity by thoroughly cleaning and disinfecting the preparation prior to sealing and placement of the restoration. Studies demonstrate slightly higher bond strengths with many dentin bonding agents when Consepsis is used because it contains no surfactants or emolients that interfere with bond strength.14
All prepared teeth were etched with 37% phosphoric acid gel and then rinsed. The wetting agent UltraCid (Ultradent) was then applied to each tooth and lightly air-dried, leaving a slightly moist surface. UltraCid contains EDTA for removal of the smear layer and benzalkonium chloride for disinfection. The manufacturer recommends using this product prior to dentin bonding, cementation, and/or restoration placement. This disinfecting solution does not contain detergents that could chemically interfere with some dentin bonding formulations.15
Prime Bond NT (DENTSPLY) was then applied to the surfaces to be bonded and light-cured. According to the manufacturer, Prime Bond NT has a unique Penta chemistry that offers adequate bonding and long-term reliability. The exclusive nano-filler technology offers reinforced hybrid and adhesive layers, protection against sensitivity, marginal integrity, low film thickness, and a simple and forgiving single-coat technique. These qualities contribute to lower sensitivity and higher strength. The modulus of elasticity minimizes leakage and sensitivity and reduces the chance of secondary caries;16 it affects a materials ability to expand or contract. Therefore, a material with a low modulus of elasticity (less expansion) will be less likely to have marginal breakdown of the bond between tooth structure and the material.

Figure 12. Final restoration preparation.	Figure 13. Interproximal cement removal using proxy disc.
;
Figure 14. Post-treatment smile.	Figure 15. Post-treatment right lateral view.
Figure 16. Post-treatment left lateral view.	Figure 17. Post-treatment occlusal view of the maxillary arch.

A salinating agent (Silane Primer [Kerr]) was applied to the internal surfaces of the all-ceramic restorations and lightly air-dried (Figure 12). Using only the translucent base material, Calibra (DENTSPLY) resin cement was used as the luting agent. The catalyst is not necessary since the restoration is translucent. Only a light-cure is necessary, which allows greater working time than if the catalyst was used for either a dual-cure or chemical-cure. Calibra is an aesthetic resin cement system that can be used for several types of cosmetic indirect restorations; it has a shade-stable chemistry so the chosen shade will not change over time. It is also both light-cured and dual-cured, with a choice of either high or regular paste viscosity, and has an ultra low film thickness (12 to 18 mm) in both viscosities. This is below the ADA acceptable maximum of 25mm, therefore reducing the potential for improper seating.17 Excess Calibra is easy to remove following cementation. ProxiDiscs (Centrix) were used to remove excess cement (Figure 13). The occlusal scheme was adjusted, and all restorations were polished. Final intraoral photographs were taken a week after delivery (Figures 14 to 17).

CONCLUSION

Figure 18. Pretreatment full-face view.	Figure 19. Post-treatment full-face view.

Due to the rise of methamphetamine use in the United States, practitioners should be able to recognize the signs of meth mouth. Dentists have the ability to help these individuals on many levels, including counseling these patients and leading them to professionals who are trained in the treatment of drug addiction. Once the patient has successfully completed a drug rehabilitation program, aesthetic dentistry can also help them rebuild their self-esteem.
In this case, the aesthetic transformation was notable (Figures 18 and 19).

References

1. American Dental Association. Methamphetamine use (meth mouth). ADA Web site, Dental Topics A-Z page. Available at: http://www.ada.org/prof/
resources/topics/methmouth.asp. Accessed: January 2006.

2. US Dept of Justice, Drug Enforcement Administration. Methamphetamine: a growing domestic threat. Federation of American Scientists Web site. Available at: http://www.fas.org/irp/agency/doj/dea/product/meth/threat.htm. Accessed:  March 2006.

3. Shaner JW. Caries associated with methamphetamine abuse. J Mich Dent Assoc. 2002;84:42-47.

4. McGrath C, Chan B. Oral health sensations associated with illicit drug abuse. Br Dent J. 2005;198:159-162.

5. Howe AM. Methamphetamine and childhood and adolescent caries. Aust Dent J. 1995;40:340.

6. Methamphetamine Awareness and Prevention Project-South Dakota. Meth mouth. Available at: http://www.mappsd.org/Meth%20Mouth.htm. Accessed: January 2006.

7. US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administra-tion, Office of Applied Studies. National Survey on Drug Use and Health. Available at: http://oas.samhsa.gov/nsduh.htm. Accessed July 29, 2005.

8. Venker D. Crystal methamphetamine and the dental patient. Iowa Dent J. 1999;85:34.

9. Brunswick M. Meth users can look forward to gumming their food. Chicago Sun Times. January 10, 2005; Drug Prevention Network of the Americas Web site. Available at: http://www.dpna.org/resources/druginfo/methgums.htm. Accessed July 29, 2005.

10. Hot health tips. CrystalNeon.org Web site. Available at: http://www.crystalneon.org/html/material. Accessed July 29, 2005.

11. 4Seasons Direct Esthetic Composite System product information. Ivoclar Vivadent Web site. Available at: http://ivoclarvivadent.com/us/en/information/html/4seasons_prodinfo.html. Accessed: January 2006.

12. Blitz N, Steel C, Willhite C. Principles of proportion and central dominance. In: Diagnosis and Treatment Evaluation in Cosmetic Dentistry. A Guide to Accreditation Criteria. Madison, Wis: American Academy of Cosmetic Dentistry. 2000:16-17.

13. IPS Empress product information. Ivoclar Vivadent Web site. Available at: http://www.ivoclarvivadent.com/com/en/products/empress_system_za/start.html. Accessed: January 2006.

14. Consepsis product information. Ultradent Web site. Available at: http://www.ultradent.com/products/products.php?act=product&fid=4&pid=65. Accessed: January 2006.

15. Ultracid product information. Ultradent Web site. Available at: http://www.ultradent.com/products/products.php?act=product&fid=4&pid=66. Accessed:  January 2006.

16. Prime & Bond NT product information. Dentsply Web site. Available at: http://www.dentsply.com/default.aspx?pageid=129#PB. Accessed: January 2006.

17. Calibra product information. Dentsply Web site. Available at: http://www.dentsply.com/default.aspx?pageid=327. Accessed: January 2006.

Dr. Morales maintains a full-time family practice focusing on cosmetic dentistry in Phoenix, Ariz. He is a graduate of UCLA School of Dentistry and is a member of the American Academy of Cosmetic Dentistry. He can be reached at (480) 283-0733.