Introduction

Drug abuse may be defined as the intentional use of illegal drugs or misuse of prescription or over-the-counter medications for their mind-altering effects. Usually these drugs are addictive. The drug may be taken orally, smoked, snorted or by intravenous injection. The spread of infectious diseases such as Hepatitis and HIV are health issues associated with sharing of contaminated needles amongst intravenous drug users (see section on Mouth and AIDS/HIV)

The cause of drug abuse is unknown. Peer pressure, depression, stress and history of abuse are amongst the factors identified that increased a person’s risk of abusing drug. However, not all people with these risks factors will abuse drugs.

The continued used of these drugs have undesirable effects on the different organs of the body, including the oral cavity. Brain damage, malnutrition, cardiac arrest or respiratory arrest are some possible complications of drug abuse.

This article will be dealing with effects of drug abuse on oral health. It first part deals with “Mouth and AIDS/HIV” and the second part deals with “Mouth and Drug Abuse”.

Mouth & AIDS/HIV

The sharing of contaminated needles among intravenous drug users contributes to the spread of infectious disease such as Hepatitis B, Hepatitis C and Human Immunodeficiency Virus (HIV).

HIV is a retrovirus which causes very slow degeneration of the human immunity system which eventually leads to the collapse the of immune system, leading to a fatal disease known as AIDS (Acquired Immuno Deficiency Syndrome).

The mouth has a lot of normal germs, which can cause irreparable damage to the mouth when the immune system is weakened. AIDS affects not only structures such the lips, tongue, gums and cheeks; it also affects the teeth indirectly.

1. What kinds of mouth (oral) problems are linked to HIV/AIDS and the treatment of HIV/AIDS.
   • The common mouth problems linked to AIDS/HIV are as follows:
     1. Oral Thrush
        Oral thrush is an infection cause by overgrowth of fungus in the mouth. It can affects lips, tongue, buccal mucosa (inside of the cheek) and palate (roof of the mouth). It may appear as white or yellow patches or red patches. The white patches can be wiped away leaving a raw area (redness) or bleeding underneath. Usually it is symptomless but it may cause a burning sensation or pain and food may taste strange (altered taste).
     2. Apthous ulcers
        • Apthous ulcers are red sores that occur on the tongue, lips and buccal mucosa (inside of the cheek). Usually slow to heal and bigger in size compared to the ulcers that occur in normal people. The top of the ulcer may appears grey-yellowish.
        • Usually painful and may affect eating, swallowing and speaking.
     3. Gum disease
        • People with HIV have a higher risk for gum disease because of reduced ability to fight against germs that invade the gums. The gum disease may range from simple (gingivitis) to a more advanced (periodontal disease) or a complex one such as ANUG (acute nectrotizing ulcerative gingivitis).
        • Their gum may appear red, swollen and bleeds easily which may cause discomfort and pain.
        • HIV positive people may experience more frequent and more severe gum disease compared to normal people.
     4. Dry mouth.
        • Dry mouth is a condition when there is not enough saliva to keep the mouth wet. Saliva production is reduced in people with HIV due to the direct effect of the virus or side effects of the ARV (Anti-retro Viral) drugs.
        • Saliva prevents the rapid accumulation of plaque on teeth and food debris in the mouth. When saliva production is reduced i.e. dry mouth, the risk of mouth soreness, apthous ulcers, infections, and tooth decay is increased (see section 3.I.a below).
     5. Oral herpes
        • Herpes is a viral infection which appears as single or multiple small blisters or ulcers affecting the roof of the mouth or the lips. Usually a burning sensation on the lips or roof of the mouth prior to the appearance of the blisters.
        • Usually painful.
   • Other less common conditions associated with HIV/AIDS.
     1. Oral pigmentation
     2. Oral hairy leukoplakia
     3. Oral lymphoma
     4. Kaposi’s sarcoma
2. What should I do to reduce the risk of mouth problems?

   People with HIV have increased risk for mouth problems. It is essential that they keep their teeth and gums healthy through proper dental care. The following are basic guidelines for good oral hygiene:

   • Carry out meticulous oral hygiene (example: brush your teeth after every meal and clean between your teeth using dental floss once a day).
   • Have a regular dental check-up eg. see your dentist every six months.
   • Eat a balance diet.
   • If you have dry mouth, keep it moist by having frequent sips of water or by chewing sugar-free gum to stimulate saliva flow. Avoid sweet drink.
   • Pay special attention to any changes in your oral health. If you notice any changes in your oral health, call your dentist for appointment.
3. What should I do when I have these mouth problems?

   Perform regular mouth self-examination. If you notice any changes in your mouth or are having any mouth problems, call your dentist or physician for an appointment. Your dentist or physician will be able to treat or relieve the symptoms.

   Common mouth problems linked to HIV/AIDS	Treatment
   Oral Thrush	Thrush can be treated with antifungal lozenges or antifungal pills depending on the severity of the infection.
   Apthous ulcers	Only symptomatic treatment and usually heal on their own. In difficult cases, prednisolone or thalidomide pills may be used.
   Gum disease	Gingivitis and Periodontal disease can be prevented and treated with regular dental visits and practice meticulous oral hygiene.
   Dry mouth	Frequent sips of water and chewing sugar-free gum may help keep the mouth moist. Aviod sweet drinks.
   Oral herpes	Use antiviral medications eg. Acyclovir.

4. Is it possible to predict my overall health based on my mouth problems?
   • The severity and frequency of mouth problems gives a rough guide to your overall health. The more severe and frequent the mouth problem you have, the weaker is your immune system.
   • The most accurate way of assessing your overall health is by measuring your viral load and the CD4 count.

Mouth & Drug Abuse

1. What kinds of mouth problems are found in people who abuse drugs regularly?
   • Prolonged used of illegal drugs leads to significant damage to the teeth and gum. The damage could be due to the chemical composition of the illegal drugs or indirectly, usually a combination of poor oral hygiene and unbalanced diet
   • The following are common mouth problems associated with prolonged illegal drug use:
     1. Dry mouth
        • The majority of illegal drugs reduce saliva production. Saliva washes and cleanses the mouth, thus preventing the rapid accumulation of plaque and food debris. This will contribute to increased risk for gum disease and tooth decay.
        • In an effort to quench their thirst, usually people with dry mouth take high sugar drinks.
        • The combination of high sugar diet with dry mouth and poor oral hygiene leads to severe tooth decay.
     2. Chemical burn and ulceration of gums.
        • The chemical composition of some street (illegal) drugs cause chemical burns on the gums.
        • Chemical burn on the gum may appear as an area of redness or ulceration. It is usually seen where the drug is being placed eg. on the gingiva in case of cocaine abuse.
        • In severe cases the underlying bone is exposed.
     3. Erosion of teeth.
        • Many street drugs are corrosive. If taken orally or applied direct to the teeth, they can cause erosion of the outer layer of tooth surfaces (enamel), thereby exposing the underlying dentine. Combined with dry mouth this will further increase the risk of tooth decay (see section on tooth decay).
        • The eroded tooth will appear dull and yellowish.
        • Street drugs that typically cause erosion of tooth surfaces are cocaine and methamphetamine.
     4. Tooth decay.
        • As explained in (c) above, tooth decay in people who abuse drugs is caused by a combination of risk factors, i.e.,
          • The acidic nature of the illegal drugs.
          • Dry mouth as side effect of the drug.
          • The tendency to have high sugar diet in order to quench thirst,
          • Poor oral hygiene.
        • Usually tooth decay associated with drug abuse are found on smooth surfaces (labial surface of front teeth and at the gum margins) and at the interproximal (between teeth) surfaces of the teeth.
        • The decay can be very severe in cases of methamphetamine (street name; Syabu, Ice) abuse. The term “Meth Mouth” is used to describe the extensive tooth decay occurring within a very short period which is typically found in methamphetamine abuser. In severe cases, the teeth are decayed to the gum line.
     5. Teeth grinding (Bruxism) and jaw clenching.
        • Bruxism is the uncontrolled grinding of the teeth. The street drugs that cause bruxism and jaw clenching are Ecstasy, Heroin and Methamphetamine. It is thought that the anxiety caused by these drugs prompt these drug users to grind their teeth.
        • If mild, usually there is no oral health issue.
        • If severe, it will cause:
          • Abnormal wear of tooth biting (occlussal) surfaces, which may predispose to sensitivity and tooth decay once the dentine surface is exposed.
          • Atypical facial pain or myofacial pain and Temporomandibular Joint (TMJ) pain.
2. What to do if you have these mouth problems?
   • First and foremost, sort out your addiction .i.e. check in at a drug rehabilitation centre.
   • Call your dentist for an appointment.
   • Carry out meticulous oral hygiene eg.brush your teeth after every meal and floss your teeth once a day.
   • Stimulate saliva flow by chewing sugar-free gum or frequent sips of water to relieve dry mouth symptoms.
   • If you have bruxism, the use mouth guard at night is recommended. The mouth guard will protect the tooth surfaces from being abraded.
3. What to look for if you suspect the person is abusing drugs, methamphetamine in particular?
   • The following are tell-tale signs of methamphetamine abuse.
     • Unexplained tooth decay within a short period.
     • Decay on smooth (labial/buccal) surfaces and at interproximal surfaces of teeth.
     • Skinny in appearance.

Summary

Many street drugs cause damage to teeth and gums, either directly or indirectly. The direct effect on the mouth (ulceration & tooth erosion) is mainly due to the drug. It is normal for drug abusers to focus on getting high on drugs most of the time. Thus normal balanced diet and good oral hygiene practices are often neglected. The combination of the drug corrosiveness, dry mouth, unbalanced diet and poor oral hygiene contributes to the increased risk of tooth decay. Tooth decay in methamphetamine abuse is usually very extensive and occurs within a short period of time, hence the term “Meth Mouth”.

The spread of HIV/AIDS amongst intravenous drug users via sharing of contaminated needle is a major health concern. Since HIV positive people have increased risk of mouth problems, it is essential that they maintain good oral hygiene, have regular visits to the dentist, and take balanced diet to ensure healthy teeth and gums.