UNDER THE INFLUENCE: INFORMING

ORAL HEALTH CARE PROVIDERS

ABOUT SUBSTANCE ABUSE
Lynn Riemer, BS,a and Ronald Holmes, MDb

ABSTRACT

SORT SCORE
A

NA

SORT, Strength of Recommendation Taxonomy

LEVEL OF EVIDENCE
1

See page A8 for complete details regarding SORT and

LEVEL OF EVIDENCE grading system

Treating the drug addicted dental patient is different than treating the non-addicted
patient due to differences related to the emotional/behavioral/personality issues of
the addict, the addicts often poor general health and poor nutrition, ongoing problems of oral hygiene and the effects of drugs on the oral mucosa, gingiva and dentition
Background
Oral health care providers need to be aware of the emerging trends in substance
abuse, able to recognize patients addicted to drugs and to be knowledgeable about
the effects of substance abuse to provide the most efcacious treatment to avoid
the consequences of contraindicated dental procedures and therapy. This article
denes the scope of the problem of drug abuse and provides an overview of
commonly abused substances and their effects on health and oral health.
Methods
A review of the literature combined with the authors extensive experience in the
substance abuse eld explains parameters of oral health care treatment of the drug
addicted individual for patient and provider safety.

a
President, ACT on Drugs. Inc.
David Dickinson Collegiate.
b

Professor of Pediatrics (Retired),

University of Michigan, Ann
Arbor, MI 48109-4280, USA

Corresponding author: ACT on Drugs. Inc., USA.

Tel.: 11 720 480 0291. E-mail: trainings@
actondrugs.org
J Evid Base Dent Pract 2014;14S:
[127-135]
1532-3382/$36.00
2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jebdp.2014.04.007

Conclusions
The drug culture has evolved and the drug user is different. Oral health care
providers need to realize that any patient may be an addict in order to identify
them, provide appropriate oral care and direct them, if they desire, toward
appropriate treatment.
Key words: Substance abuse, drug addiction, oral manifestations of substance abuse

SUBSTANCE ABUSE

Scope of the Problem

The use of illicit drugs among Americans is approaching epidemic proportions. The
2011 National Survey on Drug Use and Health prepared by the Substance Abuse and
Mental Health Services Administration reported an estimated 22.5 million Americans
aged 12 or older were current (past month) illicit drug users, meaning they had used
an illicit drug during the month prior to the survey interview1 (Figure 1). This estimate
represents 8.7 percent of the population aged 12 or older. The overall rate of current
illicit drug use among persons aged 12 or older in 2011 (8.7 percent) was similar to
the rates in 2010 (8.9 percent), 2009 (8.7 percent), and 2002 (8.3 percent), but it was
higher than the rates in most years from 2003 through 2008.
A variety of legal and illegal substances are readily available on the street or online. The
illegal status of the classical recreational substances, such as marijuana, cocaine, prescription painkillers, heroin, and methamphetamine has encouraged drug abusers to seek

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Figure 1. Past month illicit drug use among persons aged 12 or

older: 2011.1 Illicit Drugs include marijuana/hashish, cocaine
(including crack), heroin, hallucinogens, inhalants, or prescriptiontype psychotherapeutics used nonmedically.

and amount of a drug used does not necessarily constitute

addiction but it is an indicator of potential drug-related
problems. The signs and symptoms of drug use and addiction vary depending on the drug. It may be difcult to
recognize a user/addict based on appearance alone. Physical
signs that can be helpful in recognizing an abuser/addict
include blood shot eyes, changes in the size of the pupils,
unusual smells on breath, body or clothing, tremors, burns on
lips and ngers, grinding of teeth, clinching of the jaw, and
slurred speech. However, absence of these signs does not
exclude abuse or addiction. Alteration in behavior and mood
may be more indicative than changes in appearance but may
be more difcult to detect. Decline in school and work performance and changes in friends and activities may also be
revealing. Patients may miss appointments or be late for appointments and offer inconsistent excuses. There may be a
change in their appearance and they may be withdrawn.
Frequent involvement with the law or repeated loss of friends
should raise suspicion.

From Substance Abuse and Mental Health Services Administration, Results from the
2011 National Survey on Drug Use and Health: Summary of National Findings,
NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2012.

Drug Paraphernalia
Finding paraphernalia indicates drug use. Commonly identied
paraphernalia are pipes, bongs, and syringes. But paraphernalia
may be ordinary items used to disguise the drug or items used
to consume the drug: aluminum foil, small zip-lock baggies, pill
bottles, spoons, lm canisters, cigarette packs, hide-a-cans,
makeup kits, gum wrappers, tea strainers, liquid breath mint
containers or small glass vials. Items used to hide the use of
drugs include mouthwashes, breathe sprays and mints. A
strong odor of perfume or after-shave, the odor of dryer
sheets on the skin and wearing sunglasses indoors and at
inappropriate times may be signs of drug abuse. Internet sites
and smoke shops sell a variety of items used to hide drugs,
including hide-a-cans which look like common canned
products such as soda, beer, energy drinks, hair spray, WD40,
etc. but are hollow inside. They have a screw top or bottom
and are weighted. Drugs are hidden and stored inside the can.
A highlighter marker may look real, but in reality is a pipe for
smoking dope (Figures 2 and 3).

newer designer drugs that offer the advantages of being legal and
less expensive. These new designer drugs are synthetic substances produced for recreational use. Two of the most popular
families of designer drugs are synthetic marijuana and bath salts.
This article will provide: (1) an overview of the common substances of abuse including marijuana, designer drugs [synthetic
marijuana and bath salts], prescription painkillers, and methamphetamine, (2) describe the effects of drug abuse on general health
and oral health, (3) and outline the role of the oral health care
provider in recognizing and managing the drug-abusing patient.

Oral Health
Oral health care providers need to be aware of the emerging
trends in substance abuse and become knowledgeable about
the effects substance abuse has on dental/oral hygiene and
health. Providers will benet from understanding the scope of
the problem of substance abuse and recognizing that people in
all walks of life and in every socio-economic category abuse
drugs. They must also be aware that the use of illicit drugs has
both direct (induced by the drug) and indirect effects (life-style)
on oral health and oral pathology and recognize pathological
changes in the oral cavity associated with abuse of specic drugs
in order to provide the most efcacious treatment and to avoid
possible consequences of contraindicated dental treatments.

THE DRUGS

Marijuana
Marijuana is one of the most common drugs of abuse. The
belief that it is not any more dangerous than drinking alcohol
is wrong. Marijuana is used for its mood and perceptionaltering effects. The psychoactive ingredient in marijuana is a
cannabinoid, THC (delta-9-tetrahydrocannabinol), but marijuana contains hundreds of other cannabinoids. The marijuana
on the streets today is unlike the marijuana in the past it is
dangerous, addictive, and cultivated to maximize its psychoactive effect. The THC content of marijuana continues to
increase. In the 60s, 70s, and 80s THC content ranged from

IDENTIFYING DRUG USERS

Recognizing Drug Addiction

Drug abuse and addiction is less about the specic drug and
more about consequences of using the drug. The frequency

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Figure 2. Pipes disguised as highlighters.

electronic cigarettes, pens or inhalers. One section of the

device typically contains a scented liquid that is used to mask
the odor of marijuana. A favorite trick is to place a small
amount of wax on a hot paper clip and inhale the vapors
through a straw.
Marijuana joints can be laced with other drugs such as PCP,
cocaine, ecstasy, methamphetamine, heroin, or embalming
uid in order to enhance the effects and/or to hook the user
on more powerful and more protable drugs. The names of
marijuana joints often dictates how the joint is laced, i.e. black
ice is laced with methamphetamine; white rhino is laced with
cocaine; wet sticks or sherm are laced with embalming uid
(a mixture of formaldehyde and methyl alcohol). Formaldehyde is a carcinogen and inhaling formaldehyde irritates the
airways within minutes resulting in pneumonia, wheezing or
pulmonary edema (uid in the lungs).3 In the past,
formaldehyde was obtained for illicit use by stealing the
chemical from laboratories or mortuaries, but now it is
readily available for sale online.

Figure 3. Monster energy drink hide-a-can.

Effects of the Drug and Recognizing the Drug User

The desired effects of marijuana include euphoria combined
with a sense of ease and relaxation. Signs and symptoms of
marijuana abuse are provided in Box 1.
Medical Consequences
THC acts on the brain and affects memory and decisionmaking by altering normal regulation of communication
between brain cells. Recent studies conrm that THC causes
inammation in the brain by activating immune cells in the
brain that damage or destroy brain cells. This brain damage
affects learning and coordination.4
There is a signicant and consistent relationship between
marijuana use and the development of schizophrenia and
related disorders. Schizophrenia is a devastating mental illness
and people who suffer from it often experience auditory or
visual hallucinations, severe social withdrawal and cognitive
impairment. Many require frequent and prolonged hospitalization. The results of scientic studies showing an association
between marijuana use and schizophrenia and other psychiatric disorders are concerning. A 2004 article in the British
Journal of Psychiatry reviewed 4 large studies, all of which
showed a signicant and consistent association between
consumption of marijuana (mostly during teenage years or
early 20s) and the later development of schizophrenia. The
review concluded that marijuana is a causal component in
the development of schizophrenia and other psychotic disorders.5 Some people are born with an abnormal COMT gene
(1:4000 live births) that predisposes them to develop
schizophrenia or chronic depression. Up to 25% of these
people will develop depression or schizophrenia by the age
of 25 and the prevalence rate is signicantly increased if
they smoke marijuana.6

2 to 7%. Today it is around 2350%. It is important to understand that todays marijuana is a very different drug than in
the past and that it should not be looked at as just
marijuana.
Marijuana concentrate, hashish, and butane hash oil (BHO)
have become very popular. The concentrated THC oil is
extracted from the plant buds by using butane or other
chemical solvents. This liquid substance is mixed with butter
and then is known as budda. It is used to make marijuana
edibles: cookies, cakes, brownies, pies, yogurt, ice cream,
popcorn, and chocolates. However, residue from butane or
other solvents such as isopropyl alcohol or chloroform left on
the product may damage the central nervous system and the
lungs.2
Hashish may be a greenish brown solid substance or a
brownish tan waxy substance known as wax, earwax or
dabs. Wax is usually smoked in vaporizers that look similar to

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Box 1. Signs and symptoms of marijuana use

Relaxed inhibitions
Increased appetite
Distinct odor of Marijuana
Lack of motor coordination
Loss of eye convergence
Irritated mucous membranes
Distorted perception of time

Synthetic Cannabinoids (Synthetic Marijuana)

Synthetic cannabinoids are chemicals that are structurally and
functionally similar to THC. Like the THC in marijuana, synthetic THC binds to receptors in the brain and causes the
same effects and side effects of marijuana. More than 200
synthetic cannabinoids with THC-like activity have been
identied but only a few have been declared a Schedule I
controlled substance in the United States.

Difculty concentrating
Errors in judgment
Reddened eyes
Flattening of emotions
Lack of motivation
Impaired memory and
attention

1. Recognizing the Drug and Its Effects

Teens who are chronic users have reduced problem-solving
skills and exhibit cognitive inexibility. There is evidence that
long-term use impairs memory. One large epidemiological
study, performed over a period of 25 years, monitored participants from age 13 to age 38 years and documented that
chronic use of marijuana results in a loss of IQ (average 8
points). The more persistent the use, particularly during the
teen years, the greater the decline in IQ.7

The synthetic product sold in stores and online is produced

by adding raw synthetic cannabinoids to various types of dried
plant material. These products may be marketed as herbal
incense or potpourri and are sold as products not for
human consumption in order to evade regulatory scrutiny.
Abusers typically smoke or ingest the products. When
inhaled, as little as 1 mg of synthetic THC can produce
intoxication. Street names of products containing synthetic
THC include K2, Spice, Aroma, Mr. Smiley, Zohai,
Eclipse, Spike Max, Mr. Nice Guy, Black Mamba, Red X
Dawn, Blaze, Dream, Colorado Chronic, Blueberry
Mamba, and others. Packages of these drugs usually contain
35 g of material setting the stage for accidental overdose.

Withdrawal
THC is a fat-soluble drug and therefore stays in the brain and
other organs much longer than other drugs. It takes multiple
days for THC to become depleted from the brain before
withdrawal begins. Withdrawal symptoms include anxiety,
tremor, aches and pains and craving of the drug. Restlessness,
irritability, and insomnia can occur in heavy users.

The effects of synthetic THC on the brain and nervous system

are profound and may be more intense than the effects of
THC found in marijuana. Users report experiences similar to
those produced by marijuanaelevated mood, relaxation,
and altered perceptionand in some cases the effects are
even stronger than those of marijuana. Small doses have
intense side effects that are often unpredictable and include
agitation, high blood pressure, paranoia, rapid heart rate and
heart palpitations, anxiety, tremors, seizures, drowsiness,
slurred speech, dilated pupils, vomiting and chest pain.
Smoking or ingesting synthetic marijuana may cause panic
attacks and psychosis. Synthetic cannabinoids have been
implicated in the deaths of several teenagers and young adults.

Synthetic Designer Drugs

There are a wide variety of synthetic drugs available in convenience stores, smoke shops and online. Most are legal and
available without a prescription. These drugs are typically
labeled not for human consumption and are sold as plant
fertilizer, plant food, bath salts, or incense. Many designer
drugs have been banned under the Synthetic Drug Abuse
Prevention Act of 2012. However, the manufacturer simply
alters the chemical structure, not affecting the activity of the
drug, creating a new drug (not banned) and sold until the
federal agencies can prohibit its sale.

2. Medical Consequences

These drugs are available under a wide variety of names and may
be ingested, injected, smoked, or snorted. The effects may be
immediate and last several minutes to several hours to several
days. They cause a variety of effects, ranging from euphoria to
hallucinations. Users describe effects as being marijuana-like or a
combination of effects mimicking LSD, mescaline, methamphetamine, ecstasy, and cocaine. The concentration of these
drugs varies and in many cases one dose may inadvertently and
dangerously overdose the user. All these drugs are dangerous
and deaths have been reported following their use.

The composition of synthetic cannabinoid products is variable

and often unknown. As a result the side effects and medical
consequences of synthetic cannabinoids are not well documented. However, there is no reason to believe that they are
much different than the long-term effects of marijuana,
especially in view of the numerous published case reports of
recurrent panic attacks, paranoia, agitation, depression and
drug-induced psychosis that occur with marijuana intoxication
and long-term marijuana use and with the use of synthetic
marijuana.

The two most common and widely used families of synthetic

drugs are the synthetic cannabinoids and synthetic cathinones
(Bath Salts). Bath Salts are designer drugs produced for
recreational purposes and should not be confused with bath
products.

People who have an abnormal COMT gene and use synthetic

THC are likely to suffer the same effects as people who use
marijuana. Synthetic THC may also cause reduced blood
supply to the heart and a few cases of heart attack have been
reported.8 It is also known that the synthetic cannabinoid

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compounds act on the same parts of the brain as natural THC

and affect memory and decision-making.7

Disorder), Alpha-PVP (Cloud 9, Magic, Black Rob, Super

Coke) and Buphedrone. Some of these brands have chemicals in them that have a half-life of 4 days (half of the chemical
is removed from the body in 4 days) thus causing effects
lasting multiple days. Clinical features include agitation,
tachycardia, anxiety, confusion, chest pain, and nausea.

Emergency rooms report side effects ranging from convulsions and anxiety attacks to dangerously elevated heart rates,
increased blood pressure, vomiting, and disorientation. In
2012 there were more than 11,000 reported ER visits associated with the use of synthetic marijuana. Of these, 75%
were adolescents and young adults: 77.5% of these were
males.9 Acute kidney injury has been reported in teen
patients.10 Some patients have required short-term dialysis.
The responsible agent or agents have not been identied.

The 2-C series of phenethylamines are relative newcomers to

the drug scene and are very potent and dangerous. They are
known as psychedelic phenethylamines and are more potent
and longer lasting than Ecstasy. These compounds are structurally similar to mescaline and Ecstasy and are sold as a legal
substitute for Ecstasy. Street names include Smiles, Tootsie,
Blue Mystic, 7-up, Bees, Nexus, Dragon-Fly, 2-CB and Tripstasy. They are available on the street or sold online as a white
crystalline powder, tablets, or pellets. These drugs are ingested, smoked, snorted or administered rectally. The induced
high can last from 4 to 24 h with effects similar to ecstasy but
more intense. There are reported cases of people being high
for multiple days.

Bath Salts
Synthetic designer drugs with ecstasy-like properties that
mimic the effects of cathinone, a central nervous system
stimulant, have become increasingly popular among recreational drug users. Cathinone is a Schedule I controlled substance that occurs naturally in the Khat plant. Bath Salts are
chemically classied as phenethylamines containing various
substitutions. They are psychedelic drugs that stimulant the
central nervous system like methamphetamine or cocaine and
cause hallucinations like LSD, mescaline and Ecstasy.

2. Medical Consequences
Common side effects of this family of synthetic drugs include
rapid heart rate, high blood pressure, dilated pupils, increased
body temperature, paranoia, hallucinations, chest pain, suicidal
ideation, violence, and seizures. These substances have been
linked to a number of deaths from prolonged narrowing of
the blood vessels that supply the heart. This effect may persist
for days and result in sudden death from heart attack. Injection of the drugs may lead to limb ischemia (decreased blood
ow) and gangrene of the extremity distal to the injection site
(Figure 4). Other complications include agitation,
hallucinations, dilated pupils, seizure, liver failure, or kidney
failure. Toxicity is dose related.

These synthetic drugs are extremely potent. Consuming too

much causes overstimulation of the heart and heart attacks,
paranoia, acute anxiety, sweating, psychotic episodes with
paranoia, memory loss, confusion, and seizures. Mixing these
drugs with alcohol or other drugs is very dangerous. Packets of
these chemicals are labeled not for human consumption.
Package contents can be extremely pure and one dose can
cause overdose with long lasting mental defects. Synthetic
cathinones have a high addiction potential. Users have
reported that the drugs trigger intense cravings [compulsive
urge to use the drug again]. Frequent consumption induces
tolerance, dependence and strong withdrawal symptoms.
Unintentional overdose may result in severe hallucinations and
serious side effects. According to the American Association of
Poison Control Centers, calls to poison control centers
because of exposure to bath salts increased from 303 cases
in 2010 to 2676 in 2012.11 These are dangerous drugs and
have been reported to cause users to commit suicide.

Users may present with delirium accompanied by dehydration, breakdown of skeletal muscle tissue and kidney failure.
Intoxication from synthetic cathinones has proved fatal in
several instances. The dangers of bath salts are compounded
by the fact that these products may contain other unknown
ingredients that have their own harmful effects including
increased heart rate, shivering, sweating, dilated pupils, intermittent tremor or twitching, over-responsive reexes and
dangerously high body temperature. The temperature may
rise to above 41.1  C (106.0  F) in life-threatening cases.

1. Recognizing the Drug and Its Effects

All of these drugs cause a euphoric high with a rush similar to
that of cocaine, ecstasy, or methamphetamine. They typically
have little or no odor and are sold as a white, off-white, or
yellowish powder as tablets, capsules, pellets or in crystal
form. They act as appetite suppressants while giving the user
more energy. These pheenethylamines are sold on the street
or online as Methylone (MDMC, Explosion, bk-MDMA),
Naphyrone (NRG-1, 4-total), Mephedrone (Drone, M-Cat,
Meow-Meow, Bubbles, 4-MMC), MDPV (methylenedioxypyrovalerone; which is 4 times more potent than Ritalin or
Concerta used to treat Attention Decit Hyperactivity

Prescription Painkillers (Narcotics)

Opiate drugs commonly prescribed for pain-relief include
morphine, codeine, Dilaudid, Tramadol, hydrocodone (Vicodin) and oxycodone (OxyContin, Percodan, Percocet). The
US consumes 80% of the worlds painkillers. Most are prescribed to seniors but abuse is most common in the 1225
year old age group. About 55% of abusers get the drug free
from friends or family, 17% from physicians, 16% are brought
or stolen from friends or family and 4.4% from drug dealers.12

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Figure 4. Gangrene of the ngers and hand following illicit

intravenous injection of Bromo-Dragony into forearm vein.

Box 2. Warning signs of possible abuse or addiction to

prescription drugs
Using more than the recommended amount of the medication
Using prescription pills prescribed for others
Complaining of vague symptoms to get more medication
Lack of interest in treatment options other than medications
Mood swings
Seeing several physicians and/or pharmacies and/or dentists to
get more pills

Box 3. Physical signs of abuse/addiction to opiates

Constricted pupils
Skin that is cool to the touch (vasoconstriction) or excessive
sweating
Excessive yawning
Itching of face, arms and body
Ptosis on the nod
Poor coordination, drowsiness, slurred speech
Slow respiratory rate/shallow breathing
Dry mouth

These drugs have the same risks and medical/oral

complications as heroin.
Prescription drugs are a favorite among women and young
adults because they are readily available and no drug dealer is
needed. Women are 23 times more likely to be prescribed
these drugs and are about 2 times more likely to become
addicted. Those who abuse opioids may intensify their
experience by taking the drug in ways other than those
prescribed. For example, OxyContin is an oral medication but
may be snorted or injected thereby increasing the risk for
serious medical complications and overdose. The warning
signs of addiction and the physical signs of abuse/addiction are
listed in Boxes 2 and 3.

drug use reports 4.5% of high school seniors had used methamphetamines in their lifetimes, 4.1% of 10th graders, and 3.1%
of 8th graders.13
Methamphetamines may be smoked, snorted, injected, or
ingested. An intense rush (ash) appears immediately after
smoking or injecting the drug. The ash is extremely pleasurable but lasts only a few minutes. Snorting or ingesting the
drug results in euphoria without a ash, starting 35 min after
taking the drug and lasting 1520 min. One hit of methamphetamine can keep the user high for 1224 h.

Effects of the Drug

Short-term administration of prescription drugs produces
euphoria, sedation and a feeling of tranquility. Repeated use
rapidly produces tolerance (increasing the dose, reducing
intervals between doses or both) and intense physical dependence. Overdose causes respiratory depression. Continued
use of opiates makes the body rely on the presence of the drug
to maintain normal behaviors.

Methamphetamine

Effects of the Drug and Recognizing the User

Addicts experience increased wakefulness and increased
physical activity, decreased appetite, increased libido, dilated
pupils, rapid heart rate, increased blood pressure, profuse
sweating and elevated body temperature. Death may occur as
a result of hyperthermia (excessive increase in body temperature), convulsions or cardiac arrest. Someone who is high
on methamphetamine will be excited, agitated, talkative, and
restless. They may have been awake for several days and
exhibit paranoid behavior. The user is put in a state of constant ght or ight and dealing with an individual high on
methamphetamine is very dangerous. Methamphetamine
addiction has devastating physical and emotional effects on
the addict and the addicts friends/family. Rarely does the
addict return to being the person he/she was before addiction
to methamphetamine.

Methamphetamine addiction is a growing problem in the United

States, with at least 1.5 million addicts. Methamphetamine is a
powerful central nervous system stimulant and one dose may
lead to addiction. The Monitoring the Future survey of student

Medical Consequences
Methamphetamine has been associated with 2 major cardiovascular problems: heart attack and aortic dissection

Medical Consequences
Drug interaction is a major risk. If the pharmacist is not aware
of all substances a person is using a medication may be prescribed that interacts with the substance. Serious reactions
and untoward side effects may occur even with the supplemental use of over-the-counter herbal medications.

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(tearing) leading to stroke and possible death.14 Long-term

effects are psychosis, paranoia, hallucinations, loss of memory, aggressive or violent behavior, severe dental problems
and weight loss. Methamphetamine has become highly associated with risky sexual behavior thereby increasing the risk for
contracting hepatitis B or C and HIV.

Figure 5. Meth mouth.

Withdrawal from methamphetamine results in fatigue,

depression, and increased appetite. Symptoms may last for
days following occasional use and weeks or months with
chronic use. The severity is dependent on the amount of
methamphetamine used. Withdrawal symptoms may also
include anxiety, irritability, headaches, agitation, excessive
sleeping, vivid or lucid dreams and suicidal ideation.

Oral Pathology
Treating the drug addicted patient is different than treating the
non-addicted patient. These differences are related to the
emotional/behavioral/personality issues of the addict and may
put the personal safety of the oral health care provider at risk.
The addicts often-poor general health, poor nutrition and
ongoing problems of oral hygiene indirectly cause oral
pathology. Direct effects of drugs result in damage to the oral
mucosa, gingiva and dentition. Narcotics should generally be
avoided in the management of post-procedural or postoperative pain. Non-steroidal anti-inammatory agents are
preferred. The use of nitrous oxide may be problematic
because of the increased potential for cardiovascular or respiratory depression. The deleterious direct effects of the
commonly abused drugs are discussed below.

snifng, rhinitis and ulceration or perforation of the nasal

septum accompanied by a purulent nasal discharge.
Opiate Addiction
In general, narcotic addicts neglect their dental health and fail
to seek dental care when needed. They are often malnourished and eat or drink excessive sugary foods. These problems
are accompanied by xerostomia leading to increased dental
caries. Other reported problems include oral fungal and oral
viral lesions and hyperpigmentation of the tongue.17
Methamphetamines
Meth mouth is the term used to describe the predictable and
devastating effects of methamphetamine abuse (Figure 5).
Meth mouth is more likely to occur in users who inject the
drug as compared to those who smoke, inhale or ingest the
drug and is related to decreased ow of saliva the effects
the drug has on the composition of saliva. Decay is
prominent on the buccal smooth surfaces of the teeth and
the interproximal surfaces of the anterior teeth. Xerostomia
is common. All these effects are attributed to decreased
salvia ow. These problems are compounded by poor oral
hygiene, dehydration and craving sugary snacks and drinks.
Clenching of the teeth and bruxism are common and often
result in temporomandibular disorders. Young adult
methamphetamine users also tend to have missing and/or
broken teeth.

Marijuana
Long-term smoking is detrimental to periodontal tissues and
regular exposure to cannabis smoke is strongly associated
with loss of periodontal attachment. The periodontal effects
are related to the negative systemic effects of cannabis on the
immune system.15 Cannabis use has also been linked to
several other oral and dental problems including ery-red
gingivitis, gingival leukoplakia, gingival hyperplasia, uvulitis, oral
papilloma and oral carcinoma.
Bath Salts
There are no published reports about the effects of bath salts
on oral health. However, it is likely that Bath Salts (cathinones) may cause oral pathology similar to that seen in
cocaine, amphetamine and Khat abusers. Khat is a plant that
contains natural cathinones and is chewed for its euphoric
effects. It is known to cause leukoplakia, dark pigmentation of
the oral mucosa and gingival inammation.16 Severe bruxism
is common among bath salt users and results in worn teeth,
more frequent temporomandibular joint disorders and
masticatory muscle tenderness. Like cocaine, Bath Salts are
vasoconstrictors and when snorted may cause sneezing,

Providers Responsibility and Approach to the

Management of the Patient With Suspected
Drug Abuse
The drug culture today is different than in the past and the
drug user is different. There are characteristic personality and
behavioral changes that are suggestive of addiction but it is
unlikely that these changes will be evident during a visit for

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information should be offered to the patient about referral

and local treatment centers.

oral health care. Patients addicted to marijuana, designer drugs

or prescription pain killers are likely to be in good general
health and to be well groomed. Most often there are no
outward distinguishing physical characteristics that will indicate
addiction and it is difcult to identify most abusers or addicts
by looks alone. However, there may be clues apparent from
interacting with the patient and obvious ndings on the oral
examination that raise the index of suspicion for addiction.
Heroin, methamphetamine and cocaine addicts may have
some distinguishing physical ndings but in general these hardcore addicts dont seek oral health care. Providers are far
more likely to see the adolescent, woman or businessman
who is abusing or addicted to marijuana, designer drugs or
prescription drugs.

The oral health care provider must be aware that any patient
may be an addict. Although not always easy to do so, it is
important to follow ones senses and rely on what is seen,
heard and smelled. Providers have an obligation to identify
abusers/addicts and to direct them, if they so desire, to
appropriate treatment centers.

REFERENCES
1. Substance Abuse and Mental Health Services Administration. Results
from the 2011 National Survey on Drug Use and Health: Summary of
National Findings, NSDUH Series H-44, HHS Publication No. (SMA)
124713. Rockville, MD: Substance Abuse and Mental Health Services
Administration; 2012.

Visual observance is critical. Are the patients eyes red or is

the patient having problems focusing? Are their pupils
dilated or constricted? Are the agitated? Are they breathing
normally? Is there an unusual burn on their mouth or
ngers that could signify smoking a hot metal or glass pipe?
Have they developed nosebleeds indicative of snorting
cocaine or bath salts? Are they wearing long sleeves even
in the middle of summer as a way to hide track marks
from intravenous drug use.

2. Garland EL, Howard MO. Volatile substance misuse: clinical considerations, neuropsychopharmacology and potential role of pharmacotherapy in management. CNS Drugs 2012;26(11):927-37. http:
//dx.doi.org/10.1007/s40263-012-0001-6.
3. US Department of Labor. OSHA, Occupational Safety and Health
Standards. Subpart Z; 1910:1048. App C.
4. Cutando l, Busquets-Garcia A, Puighermanal E, et al. Microglial activation
underlies cerebellar decits produced by repeated cannabis exposure.
J Clin Invest 2013;123(7):2816-31. http://dx.doi.org/10.1172/JCI67569.
Epub 2013 Jun 24.

Odors can be indicative. Marijuana has a distinctive odor.

Strong pleasant odors, like breath mints or heavy perfumes,
can be attempts at covering or masking drug odors.

5. Arseneault L, Cannon M, Witton J, Murray RM. Causal association

between cannabis and psychosis: examination of the evidence. Br J
Psychiatry 2004;184:110-7. http://dx.doi.org/10.1192/bjp.184.110.

Listening is an important component of assessment. Clues are

evident by the things being said, what is laughed at or the fact
that nothing at all is being said. Silence can speak volumes. Are
patients slurring words? Are they speaking in a low and raspy
or high pitched and fast voice? Are they able to follow the
conversation? Are they taking a long time to answer?

6. Pelayo-Tern JM, Surez-Pinilla P, Chadi N, Crespo-Facorro B. Geneenvironment interactions underlying the effect of cannabis in rst
episode psychosis. Curr Pharm Des 2012;18(32):5024-35.
7. Meier HM, Caspi A, Ambler A, et al. Persistent cannabis users
neuropsychological decline from childhood to midlife.
Natl Acad Sci U S A 2012;109(40):E2657-64.
//dx.doi.org/10.1073/pnas.1206820109. published ahead of
August 27, 2012.

If these general observations raise a suspicion for abuse/

addiction or if the ndings on oral examination suggest substance abuse, the oral health care provider has a responsibility
to ask the patient matter-of-factly about abuse. Queries can
and should be made without being judgmental or confrontational. It is important to keep the tone of voice and body
language neutral and to be certain that the approach and
choice of words is appropriate for the age of the patient. The
indications of the oral ndings should be carefully outlined and
explained to the patient. One may ask, Have you been using
any medications or other substances, not prescribed by your
health care provider, which could harm your health? If in
doubt about what to do, it is wise to discreetly, privately and
condentially discuss your ndings with a colleague. If the
patient is under 18 years old there is an obligation to discuss
the ndings and what they mean with the parent or guardian.
However, it is always best to discuss your concerns with older
teens and let them know that you plan to contact their
parent/guardian. If the patient is 18 years or older, the ndings
and their signicance should be discussed. Written

Volume 14, Supplement 1

show
Proc
http:
print

8. Hermanns-Clausen M, Kneisel S, Szabo B, Auwarter V. Acute toxicity

due to the conrmed consumption of synthetic cannabinoids: clinical
and laboratory ndings. Addiction 2013;108(3):534-44. http:
//dx.doi.org/10.1111/j.1360-0443.2012.04078.x.
9. Substance Abuse and Mental Health Services Administration. Drug
Abuse Warning Network, 2011: National Estimates of Drug-related
Emergency Department Visits. HHS Publication No. (SMA) 134760,
DAWN Series D-39. Rockville, MD: Substance Abuse and Mental
Health Services Administration; 2013.
10. Centers for Disease Control and Prevention (CDC). Acute kidney injury
associated with synthetic cannabinoid use - multiple states, 2012. Morb
Mortal Wkly Rep February 15, 2013;62(6):93-8.
11. American Association of Poison Control Centers. http://www.aapc.org/
alerts/bath-salts.
12. Centers for Disease Control and Prevention. http://www.cdc.gov/
homeandrecreationalsafety/rxbrief/.
13. Johnston LD, OMalley PM, Bachman JG, Schulenberg JE. The Rise in
Teen Marijuana Use Stalls, Synthetic Marijuana Use Levels, and Use of

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bath Salts is Very Low. Ann Arbor, MI: University of Michigan News
Service; December 19, 2012.

16. Yarom N, Epstein L, Levi H, Porat D, Kaufman E, Gorsky M. Oral

manifestations of habitual khat chewing: a case-controlled study. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(6):e60-6. http:
//dx.doi.org/10.1016/jtripleo.2010.02.022.

14. Swalwell CL, Davis GG. Methamphetamine as a risk factor for acute
aortic dissection. J Forensic Sci 1999;44(1):23-6.

17. Westerhof W, Wolters EC, Brookbakker JT, Boelen RE, Schipper ME.
Pigmented lesions of the tongue in heroin addicts-xed drug eruption. Br
J Dermatol 1983;109:605-10.

15. Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J

Psychiatry 2001;178:101-6.

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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUEANNUAL REPORT ON DENTAL HYGIENE

SUGGESTED READING
1. Substance Abuse and Mental Health Services Administration. Results
from the 2011 National Survey on Drug Use and Health: Summary of
National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12
4713. Rockville, MD: Substance Abuse and Mental Health Services
Administration; 2012.
2. Gunderson EW, haughey HM, AIt-Daoud N, Joshi AS, Haart CL. Spice
and K2 herbal highs: a case systematic review of the clinical effects and
biopsychosocial implications of synthetic cannabinoids use in humans. Am
J Addict 2012;21(4):320-6. http://dx.doi.org/10.1111/j.1521-0391.
2012.00240.x. Epub2012 Apr23.

Volume 14, Supplement 1

3. American Association of Poison Control Centers. http://www.aapc.org/

alerts/bath-salts.
4. Centers for Disease Control and Prevention. http://www.cdc.gov/
homeandrecreationalsafety/rxbrief/.
5. Johnston LD, OMalley PM, Bachman JG, Schulenberg JE. "The Rise in
Teen Marijuana Use Stalls, Synthetic Marijuana Use Levels, and Use of
bath Salts is Very Low. Ann Arbor, MI: University of Michigan News
Service; December 19, 2012.
6. Shetty V, Mooney M, Corwin ZM, Belin TR, Murphy D, Rawson R. The
relationship between methamphetamine use and increased dental disease. J Am Dent Assoc 2010;141:307-18.

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