JADA Continuing Education
Comparing diet, oral hygiene and caries status of adult methamphetamine users and nonusers
A pilot study
Kimberly A. Morio, BS,
Teresa A. Marshall, PhD, RD/LD,
Fang Qian, PhD and
Teresa A. Morgan, DDS, MS
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ABSTRACT
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Background. Methamphetamine users are reported to have marginal dietary habits and high caries rates. The authors compared retrospective dietary patterns, oral hygiene behaviors and current oral health status of methamphetamine users and nonusers in a pilot study.
Methods. Eighteen adults with a history of methamphetamine use (methamphetamine users) and 18 age- and sex-matched control subjects (nonusers) completed retrospective questionnaires concerning meal patterns, food group intakes, beverage habits, oral hygiene behaviors, smoking behaviors and drug use. The authors performed oral examinations to identify the number of remaining teeth, the number of teeth with obvious decay and presence of visible plaque.
Results. Methamphetamine users were more likely to snack without eating defined meals (P = .026), consume regular soda pop (that is, carbonated beverage with sugar) (P = .018), never brush their teeth (P < .001) and smoke (P < .001) than were nonusers. Users had more visible plaque (P < .001), fewer molars (P = .001) and more decay on anterior teeth (P < .001), premolars (P < .001) and molars (P < .001) than did nonusers.
Conclusions. The results of this pilot study are consistent with anecdotal reports; methamphetamine users have more gross caries than do nonusers. Marginal dietary and oral hygiene behaviors associated with methamphetamine use likely increase caries risk.
Clinical Implications. Patients at risk or suspected of using methamphetamine require detailed oral hygiene instruction and extensive dietary counseling.
Key Words: Drug abuse; methamphetamine; caries; oral hygiene; diet; carbonated beveragesAbbreviations: BMI: Body mass index. • DMFT: Decayed, missing or filled permanent teeth. • IRB-01: Institutional Review Board-01 Biomedical.
Methamphetamine is a highly addictive central nervous system stimulant that is synthesized easily from readily available precursors and with the use of minimal equipment in makeshift, often-mobile laboratories. Increased availability of both imported and locally produced methamphetamine has led to increased rates of abuse in the rural Midwest. Iowa reported having the eighth highest rate of methamphetamine use and the second highest number of methamphetamine laboratory responses (police, federal or other investigations of a methamphetamine laboratory) in the United States in 2004. However, methamphetamine laboratory incidents were 78 percent lower in 2006 than in 2004 after the over-the-counter agent pseudoephedrine was classified as a Schedule V controlled substance in 2005 and started being sold only behind the pharmacy counter.1,2
Methamphetamine use is destructive to individual people, families and communities. Idiopathic pulmonary arterial hypertension, memory impairments, executive functioning deficits, dental decay and potentially fatal cardiac crises are among the systemic conditions associated with methamphetamine.3–8 Methamphetamine use was involved in 49 percent of child abuse cases in southwestern Iowa during 2005; job instability and illegal activities resulting from methamphetamine use also disrupt family life.2,9 Crime, rage-associated behaviors, risky sexual behaviors and methamphetamine laboratory cleanup affect communities with a high prevalence of methamphetamine use.9–11
The term "meth mouth" has been used in the literature to describe a pattern of rampant caries that is observed in methamphetamine users.7,8,12,13 The exact etiology of meth mouth is unknown; however, contributing factors are thought to include frequent, excessive sugared-beverage intake secondary to dry mouth associated with hyposalivation, poor oral hygiene and acidic ingredient contaminants remaining in methamphetamine after it is manufactured. There are anecdotal reports of "meth mouth" in Iowa, as elsewhere, with little supporting evidence.
Shaner and colleagues12 described the oral health of a 25-year-old patient who had a seven-year history of daily methamphetamine use. The patient reported having dry mouth while using methamphetamine, resulting in a two-liter per day carbonated beverage intake habit. A year after discontinuing methamphetamine use, the patient came to the dental clinic with rampant caries, generalized calculus and a plaque index of 95 percent.
Saini and collaegues13 described the oral health of five methamphetamine users. Three of these users reported having high intakes of carbonated beverages, fruit juice or both. They were all were male and had decayed, missing or filled permanent teeth (DMFT) scores of 31 or greater. The other two users were female. They had DMFT scores of 7 and 5, and they consumed high quantities of carbonated beverages and fruit juice, respectively.
These case reports suggest that some methamphetamine users have rampant caries, and they support anecdotal reports of a pattern of rampant caries among methamphetamine users. Research on meth mouth and related risk factors, however, is lacking in the scientific literature.
Concurrent with the increased rates of methamphetamine use in rural Iowa, we saw an increase in anecdotal reports and suspected cases of meth mouth at the University of Iowa College of Dentistry (Iowa City). We conducted a pilot study to compare the retrospective dietary patterns, oral hygiene behaviors and current oral health status of people with a history of methamphetamine use (methamphetamine users) and people with no history of methamphetamine use (nonusers).
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SUBJECTS AND METHODS
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Subjects.
We recruited people older than 18 years from the University of Iowa’s Oral and Maxillofacial Surgery clinics for participation in a case-control study. All of the subjects were scheduled to undergo an extraction of at least one tooth. We identified 18 study subjects (methamphetamine users) when they voluntarily disclosed on their health history form or during the eligibility screening that they had previously used methamphetamine.
We recruited 18 age- and sex-matched control subjects (nonusers) from the same patient pool. To be eligible to be a control subject, patients could not report on their health history form or during the eligibility screening that they had a history of methamphetamine use.
The University of Iowa’s Institutional Review Board-01 Biomedical (IRB-01) approved all components of the study. The subjects’ participation was voluntary, and we obtained written, informed consent from the subjects.
Data collection.
We obtained demographic data and medical histories, including reported drug use, from the subjects’ dental records.
We gathered information concerning subjects’ meal patterns, food group intakes, beverage habits, oral hygiene behaviors, smoking behaviors and drug use via a questionnaire that was administered during dental appointments. (Per IRB-01’s guidelines, we required subjects to complete a written questionnaire rather than participate in an oral interview.) We asked methamphetamine users to reference the period when their use was highest when completing the questionnaire. We asked nonusers to reference the period two years earlier when completing a similar questionnaire.
Using a portable scale and a portable stadiometer, we measured subjects’ weight and height while they were wearing their street clothes but not their shoes. We calculated each subject’s body mass index (BMI), by dividing the weight in kilograms by the height in square meters.
A dentist, dental student or both conducted a visual oral examination to identify the number of remaining teeth, the number of teeth with obvious decay and the presence of visible plaque.
Statistical analyses.
We conducted statistical analyses by using a statistical software package (SAS for Windows, Version 9.1 SAS Institute, Cary, N.C.). We calculated descriptive statistics. We report variables as percentages of subjects or means ± standard deviations. We used the Fisher exact test, the 
2 test and the nonparametric Wilcoxon rank sum test to identify differences between methamphetamine users and nonusers. The level of significance was P < .05.
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RESULTS
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The average age of methamphetamine users and nonusers was 31 ± 6 years, and 76 percent of all subjects were male. Users were less likely to have private dental care coverage (that is, insurance or self-pay) (33 percent) than were nonusers (81 percent) (P = .007).
The average BMI of methamphetamine users (18.2 ± 2.4) that we calculated from their reported weights at the time of their peak use was less than that of nonusers (22.5 ± 7.1) that we calculated from their reported weights two years earlier (P = .004). Weight gain, which we calculated on the basis of reported and current weights, was greater for users (33 ± 25 pounds) than for nonusers (1 ± 11 pounds) (P < .001). The BMIs we calculated on the basis of current weights did not differ between users and nonusers (P = .400).
Methamphetamine users were more likely to use tobacco products (94 percent) than were nonusers (28 percent) (P < .001). Seventeen users smoked a mean of 32 ± 16 cigarettes per day, and one also used smokeless tobacco. Four nonusers smoked a mean of 19 ± 5 cigarettes per day, and only one used smokeless tobacco.
Dietary.
Table 1
shows subjects’ meal patterns at the time of peak methamphetamine use for users and two years earlier for nonusers. Users were less likely to consume defined breakfasts, lunches and dinners and were more likely to snack without eating meals or to forgo food one or more days a week than were nonusers.
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TABLE 1 Meal patterns at the time of peak methamphetamine use for users (n = 18) and two years earlier for nonusers (n = 18).
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We also compared the frequency of food group servings between methamphetamine users and nonusers. We asked the subjects how often they consumed food from each food group. We found that the frequencies varied from those recommended by the U.S. Department of Agriculture Food Guide Pyramid for adults to less than once a week. We compared categorical responses using the Fisher exact test. The frequency of fruit consumption did not differ between users and non-users (P = .108); 0 percent of users consumed fruit three or more times daily compared with 11 percent of nonusers, and 78 percent of users consumed fruit less than four times per week compared with 44 percent of nonusers. Users consumed vegetables less frequently than did nonusers (P < .001); 11 percent of users consumed vegetables one to two times daily compared with 56 percent of nonusers, and 39 percent of users consumed vegetables less than once a week compared with 0 percent of nonusers. Users consumed bread products less frequently than did nonusers (P < .002); 6 percent of users consumed bread products one to five times daily compared with 44 percent of nonusers, and 44 percent of users consumed bread products less than once a week compared with 0 percent of nonusers. Users consumed meat and meat alternatives less frequently than did nonusers (P < .001); 0 percent of users consumed meats and meat alternatives two or more times daily compared with 33 percent of nonusers, and 28 percent of users consumed meats and meat alternatives less than once a week compared with 0 percent of nonusers. Users consumed dairy products less frequently than did nonusers (P < .025); 6 percent of users consumed dairy products two or more times daily compared with 28 percent of nonusers, and 22 percent of users consumed dairy products less than once a week compared with 6 percent of nonusers.
Table 2 shows beverage consumption patterns at the time of peak methamphetamine use for users and two years earlier for nonusers. Users were more likely to consume regular soda pop (that is, a carbonated beverage with sugar) and less likely to consume other sugared beverages and sugar-free beverages than were nonusers. The variability in weekly frequency of consumption and serving sizes of regular soda pop for users was high, resulting in differences in daily regular soda pop intakes between users and nonusers that approached, but did not achieve, the statistical significance level of < .05. Among those who consumed other sugared beverages, users reported having higher weekly frequencies of consumption and, thus, higher weekly intakes, than did nonusers.
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TABLE 2 Beverage consumption habits at the time of peak methamphetamine use for users (n = 18) and two years earlier for nonusers (n = 18).
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We also asked subjects about their access to adequate and appropriate food either at the time of peak methamphetamine use for users and two years earlier for nonusers. Both users (89 percent) and nonusers (100 percent) reported having "access to enough food to prevent hunger" (P = .486). Furthermore, 72 percent of users and 94 percent of nonusers reported having "access to the right kinds of food for good nutrition" (P = .212).
Oral health.
Table 3 shows the oral health status of methamphetamine users and nonusers at the time we performed the oral visual examinations. Users had similar numbers of anterior teeth and premolars as nonusers, but they had fewer molars. Users had a higher percentage of anterior teeth, premolars and molars with decay than did nonusers. Five users and two nonusers had gross decay on all of their teeth. Ninety-four percent of users had visible plaque on their teeth compared with 24 percent of nonusers.
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TABLE 3 Oral health of methamphetamine users (n = 18) and nonusers (n = 18) at the time of the visual oral examination.
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Table 4 shows oral hygiene behaviors at the time of peak methamphetamine use for users and two years earlier for nonusers. Users were more likely to never brush their teeth than were nonusers. Flossing frequencies did not differ between users and nonusers.
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TABLE 4 Oral hygiene behavior at the time of peak methamphetamine use for users (n = 18) and two years earlier for nonusers (n = 18).
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DISCUSSION
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Our results suggest that methamphetamine users have poorer dietary habits, practice oral hygiene less often and have more caries than age- and sex-matched nonusers. These data are consistent with anecdotal descriptions7,8 of meth mouth and the case reports described by Shaner and colleagues12 and Saini and colleagues.13 The rampant caries or meth mouth observed in the subjects in our study likely are associated with poor diet quality, excessive sugared-beverage consumption and inadequate oral hygiene. Although poor diet quality generally is not considered to be a risk factor for caries, replacing foods from the basic food groups (fruits, vegetables, breads, meats and meat alternatives, and dairy) with processed foods that have high amounts of sugar and sugared beverages is associated with caries.14–16 Furthermore, snacking rather than eating defined meals would be expected to increase exposure frequency and, therefore, caries risk.17
Methamphetamine is an appetite suppressant, and its use has been associated with periods of food avoidance.18 In our study, we found that methamphetamine users were more likely than nonusers to skip meals, snack rather than eat meals and consume no food for entire days. The quality of user’s diets, as determined by food group intakes, also was poorer than that of nonusers’ diets. Seventy-two percent of users, however, reported having had access to adequate and appropriate food during their time of peak methamphetamine use.
More methamphetamine users than nonusers reported consuming regular soda pop and having more frequent regular soda pop consumption; however, variability in serving sizes among users and nonusers resulted in differences in daily intakes that approached, but did not achieve, statistical significance. Although fewer users than nonusers consumed other sugared beverages, users’ consumption was more frequent and resulted in higher total intakes. Sugar cravings, coupled with dry mouth that likely was secondary to hyposalivation, are thought to contribute to excessive sugared-beverage intake.7,8,12,13,19,20 Even though anecdotal reports suggest that methamphetamine use is characterized by high sugared-beverage intakes, there also are nonusers who consume excessive quantities of regular soda pop.
We found that the oral health status of methamphetamine users was worse than that of nonusers. Users had fewer molars than did nonusers, and, although we speculated that the teeth were lost to decay, we do not know the reason for their loss. Users had higher percentages of anterior teeth, premolars and molars with gross decay than did nonusers, which is consistent with anecdotal reports and case reports.7,8,12,13 Again, there was considerable overlap within our patient population; two nonusers had significant patterns of decay.
Our study had several limitations. First, the dental examinations we conducted were visual and did not include tactile or radiographic examination. Second, the University of Iowa Institutional Review Board did not allow oral administration of questionnaires. Written questionnaires require reading and additional processing, and we observed that methamphetamine users needed more time to complete their questionnaires than did nonusers. Furthermore, chronic methamphetamine use can affect cognitive performance and memory; thus, data reported by users could be questionable.
Adults selecting the University of Iowa rather than a private clinic for oral surgery treatment are not necessarily representative of the general Iowa population. A significant number of potential control subjects became study subjects when we asked them about their history of methamphetamine use, limiting the number of control subjects and overall sample size.
Finally, two study subjects who denied using methamphetamine had an oral health pattern consistent with that of users (all teeth exhibited gross decay) and answered all questions "correctly." Although we questioned the validity of their responses, we included them in the control group because they denied using methamphetamine. We expect that including these subjects in the control group minimized the differences in dietary and oral hygiene behaviors between methamphetamine users and nonusers.
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CONCLUSIONS
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The findings of our study are consistent with anecdotal reports; methamphetamine users have more gross caries than do nonusers. Poor diet quality, more frequent snacking, higher sugared-beverage intake and less toothbrushing are behaviors that could contribute to rampant caries in this population. Additional investigation of relationships between risk factors and caries in methamphetamine users is necessary to understand fully the disease process in this population.
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FOOTNOTES
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Ms. Morio is a dental student, Department of Preventive and Community Dentistry, University of Iowa College of Dentistry, Iowa City.
Dr. Marshall is an assistant professor, N335, Dental Science Building, University of Iowa, Iowa City, Iowa 52242, e-mail "teresa-marshall{at}uiowa.edu". Address reprint requests to Dr. Marshall.
Dr. Qian is an associate research scientist, Department of Dows Research, University of Iowa College of Dentistry, Iowa City.
Dr. Morgan is an assistant professor, Department of Oral and Maxillofacial Surgery, University of Iowa Health Care, University of Iowa, Iowa City.
Portions of this study were presented as posters at the general sessions of the International Association for Dental Research in Orlando, Fla., in 2006, and in New Orleans, in 2007.
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ABSTRACT
SUBJECTS AND METHODS
