Meth mouth

The image above represents what is commonly referred to as Meth mouth. The first thing that strikes you is the tooth decay, but if you look carefully, you can see a lot more going on. Note the red, swollen, irregular borders of the gums, and the yellowish white plaque which coats the teeth where they meet the gums. Meth mouth is really about more than rampant tooth decay. It is a lifestyle issue.

The general public associates meth mouth with people who are addicted to methamphetamines. Let me assure you that the syndrome called meth mouth is NOT always associated with an addiction to methamphetamine, or with any other drug for that matter. Long before the widespread use of amphetamines, the condition you are looking at occurred in people who lived under conditions of prolonged stress, poor nutrition, poor oral hygiene, and high sugar intake.

In the mid 1970's, during a dental school externship, I had occasion to work in an emergency room in an impoverished part of one of the exurbs of Boston. Most of the time, when I saw cases like this, the patient was a young woman, often a single mother living on welfare. Others were prostitutes. Some were cocaine or heroine addicts. Methamphetamine was not a popular drug at that time, so it was rarely a contributor to their problems. These women would come to the emergency room because of very sore gums which made it difficult to eat. They also had a high fever, waves of nausea and very bad breath. The decay in their teeth was a secondary concern, and was an ongoing problem for them, but it did not constitute the reason for their visit to the emergency room.

The pain in their gums, their fever and their inability to function was caused by a condition known as Acute Necrotizing Ulcerative Gingivitis (or ANUG for short). You can see a localized area of ANUG in this detail from the image at the top of the page. Notice the redness, swelling and erosion of the gum margins in this area. This is what an acute infection of the gums looks like. Even touching this area with a cotton swab is painful. I can bring you the image, but I cannot convey the odor. Notice the mounds of bacterial plaque coating the roots of the teeth. Oral bacteria (plaque) can actually eat a living body. ANUG happens only to persons who neglect their oral hygiene and who's immune system has been compromised by prolonged stress, malnutrition or other chronic diseases such as HIV.

The treatment for this condition is actually fairly easy. We just clean around the teeth with hydrogen peroxide on a cotton swab and give the patient a prescription for penicillin (or clindamycin if they are allergic to penicillin). The infection clears up in a few days, and while the gums never regain their old scalloped appearance, they do heal and maintain their health with a later professional cleaning and improved oral hygiene. In persons who do not seek treatment, the condition may eventually clear spontaneously, only to reappear again at a later date.

Why do some non-addicts have this type of problem while others do not?

What is important is not so much the appearance or treatment of rampant tooth decay and ANUG, but what caused these problems in the first place. You don't have to be a meth addict to have a mouth that looks like this! These women were living in impoverished conditions. They were frequently subject to abuse by boyfriends or pimps. Some were addicted to heroine or cocaine (methamphetamine was not as common in those days as it is today). They rarely brushed their teeth. They also tended to ignore their nutrition, their diet consisting mostly of soda and sweet snack foods. The reasons that any person, including non-addicts, may have mouths that look like this are as follows:

Gum infection

High stress and bad nutrition tend to suppress the immune system which is responsible for fighting off the germs that live in the mouth. The bacteria in plaque (the soft paste that accumulates on the teeth at the gum line) get the upper hand in these people and begin to dissolve (rot) the gums. When bacteria attack living tissue, the condition is called an infection. ANUG is simply an acute infection.

Tooth decay

The very high sugar content in the diets of these patients, along with poor oral hygiene allows the bacteria in plaque to create acids which dissolve their teeth, especially around the gum line where the concentration of plaque is the highest. This is what causes the rampant tooth decay.

Broken teeth

High stress lifestyles also cause people to grind their teeth as a way of relieving the stress. This is called Bruxing and is covered on my pages covering dental headaches (TMJ). Severe bruxing increases the severity of the damage to the teeth caused by decay, and in addition it causes the already weakened teeth to break.

All this, and we haven't even discussed methamphetamines.

How Meth mouth got its name

The condition in the image at the top of this page got the name Meth Mouth sometime toward the end of 2004 or early 2005 when it became a major problem for the corrections personnel responsible for processing new inmates in city jail populations. (Jail is where prisoners are incarcerated before sentencing.) Prior to this time, rampant tooth decay was not uncommon in these populations, but authorities began to notice a sudden sharp increase. Furthermore, before this time, the combination of rampant caries and ANUG in persons arrested for violent crimes was less common. Since the overt illness caused by ANUG necessitated a trip to the emergency room, or, at minimum, in-house treatment prior to incarceration, the recent increase in arrests of persons with this combination of oral issues prompted city officials to look for the cause of the problem. It was not too long before they discovered that most of the prisoners presenting with the combination of rampant decay and ANUG were methamphetamine addicts.

What was especially unusual was the fact that ANUG was now occurring in conjunction with the violent behavior that caused the arrest in the first place. ANUG makes the patient quite ill. Most people who feel sick don't want to be overly active----unless they are high on meth. Methamphetamine makes people forget that they are sick. It also promotes the violent and otherwise screwy behavior that leads to arrest. Now that methamphetamine was becoming the drug of choice for both male and female criminals as well as prostitutes, these changes in behavior caused a sudden increase in arrests of persons suffering from the combination of acute gum disease and serious tooth decay.

For most practitioners, the main characteristic of note was the tremendous increase in tooth decay occurring since the meth epidemic began, not to mention the increase in violent and self destructive behavior. ANUG, being a less common feature, took a back seat, and most commentators barely mention it when discussing meth mouth. It must be remembered, however that acute gum infections are very much a part of the meth mouth syndrome.

While addiction to other drugs reduce the quality of life, and can be associated with the same oral manifestations as meth, methamphetamine appears to be especially virulent in this respect.

The signs and symptoms of Meth mouth

In medicine, the term "signs" means those things that the doctor or other people can see, feel, hear or smell, while the term "symptoms" refers to things the patient can sense and are not necessarily apparent to the doctor or other people. In other words, signs are objective, while symptoms are subjective. Some of the signs of meth mouth are visible in the photograph above, while others are not visible in the image. The objective signs include:

Rampant tooth decay, especially around the gum line
Recurrent ANUG. This may resolve itself without treatment, but will generally return again later. This may happen over and over again.
Broken teeth. Pictured to the right, broken teeth frequently happen due to the weakening of the tooth because of the decay at the gum line and between the teeth.
Attrition of the teeth. This means wear of the enamel of the teeth due to constant grinding.
Seriously bad breath. This becomes worse during periods of ANUG, but remains a problem, usually due to poor hygiene and dry mouth.
Abscessed teeth. This happens when the decay kills the nerve in the tooth.

The subjective symptoms the patient experiences include the following:

Serious tooth pain. From abscesses and acute nerve pain due to decay.
Pain in the gums when eating. This happens especially during acute periods of ANUG.
Fever, malaise, nausea. These symptoms happen due to acute infections like tooth abscess and ANUG.
Headaches, neck aches, jaw aches. These symptoms relate to severe bruxing (grinding and clenching) of the teeth.

How does meth cause these signs and symptoms?

Methamphetamines are in a class of drugs which are termed "central nervous system stimulants". This places them in the same class as cocaine, PCP, ecstasy and other drugs which cause people to feel more awake and stimulated. The difference is that Meth is like these other drugs on steroids! Methamphetamines cause the following effects on the human body:

Destructive lifestyle. Methamphetamine, popularly shortened to meth and also nicknamed "ice" or "Speed", is addictive. In other words it produces an initial pleasurable effect, followed by a rebound unpleasant effect. It starts with an "up" and is followed by an unpleasant "down" which can be avoided by taking more of the drug. The longer the "up" is maintained, the worse the "down" feels, and the harder the addict will seek the drug to maintain the high. The harder the addict seeks the drug, the less attention he/she pays to his/her other bodily needs. Addicts stop caring for themselves, neglecting oral and personal hygiene, and they stop eating the foods that normal people crave and substitute soda and candy. They even go for days at a time without sleep.
- Poor oral hygiene leads to periodontal disease interspersed with acute gum infections (ANUG). It also leaves masses of plaque around the gum line and between the teeth. Plaque is made of almost pure bacteria.
- Sugary foods and drinks cause the mass of plaque to become acidic causing tooth decay. Whenever the patient eats or drinks sugared foods, this leads to the massive (rampant) decay (caries) you see in the image at the top of the page.
- The substitution of sugar for nutritious foods affects the immune system, reducing the addict's resistance to various diseases including chronic gum disease and ANUG.
- The lack of sleep also helps to further weaken the addicts immune system.
In the end, the association of the addict with other addicts brings about not only an addiction to the drug, but also an addiction to the lifestyle itself. Lifestyles involve not just the drug, but the friends the addict makes, the types of amusements he enjoys, the foods he eats, and even the level of abuse and violence that the individual comes to expect in his or her life. (Yes, people do become addicted to physical abuse, and even fall in love with their abusers!) Most addicts find that breaking the addiction to the drug is much easier than breaking the addiction to the lifestyle. This is the reason that so many addicts who kick their drug habit eventually go back to the old habits and become addicted to the drug again. Meth is not the only drug that can cause people to loose interest in living, but it appears to be more likely than other drugs to do it.

The image above shows what can happen to a person who becomes addicted to methamphetamine. The difference between the before and after shots is less than three years. While this essay dwells on what meth can do to the inside of the mouth, one should always bear in mind that meth mouth is only a part of the overall story.
The physiologic effects of the drug. Methamphetamine is a psychostimulant and sympathomimetic drug. It works on the brain and triggers a cascading release of norepinephrine, dopamine and serotonin. These are all neurotransmitters which help the neurons (brain cells) to pass electrical signals to each other. It causes euphoria and excitement, and also an increase in focus, increased mental alertness, and the elimination of fatigue, as well as a decrease in appetite. The effects are something like those of adrenalin (epinephrine), the fight or flight hormone. It causes a number of physiological effects which relate to meth mouth:
- Excessive sweating and diarrhea. Both of these effects bring about dehydration and cause the addict to have a ferocious thirst. This leads him or her to drink excessive amounts of fluid, most of which turns out to be soda and other sugared soft drinks.
- Loss of appetite. The body craves energy, and in view of the ferocious thirst mentioned above, the addict will generally turn to sugary soft drinks to compensate for the reduction in calories generated by the destruction of the appetite.
- Dry mouth. This is ultimately due to the excessive sweating and diarrhea. Unfortunately, the dry mouth has serious consequences for the addict. The lack of saliva and dry conditions in the mouth cause a shift in the bacterial flora (the mix of germ species in the mouth) toward bacteria that produce more acid from the sugar consumed in the ubiquitous soft drinks the addict is likely to consume. This causes the decay to advance much faster than would otherwise happen in a patient without a dry mouth.
- Muscular hyperactivity. This is due to the increased mental alertness and excitement caused by the cascading release of the neurotransmitters mentioned above. This causes bruxing (grinding) and clenching of the teeth. These habits in turn cause the following problems:
  - Broken teeth. The constant grinding and clenching place a great deal of pressure on the decay weakened teeth and cause them to break.
  - Attrition. The constant movement of the jaws as the teeth slide over each other causes serious wear on the teeth that have not already broken.
  - Headaches, earaches and jaw aches. This is serious pain caused by the overuse of the muscles that close the jaws. It is similar to having a cramp in your leg, only the way the chewing muscles are leveraged causes the pain to be constant. Click here for more on dental headaches.
  - Joint damage. The joint in question is the temperomandibular joint (the TMJ) which is the joint that allows you to open and close your jaw. Over time the joint deteriorates due to the constant pressure. Click here for more on joint dysfunction.
Can my Meth Mouth be treated?

The answer to this question depends very much on you!
- If you are still hooked, or are actively engaged in an addictive lifestyle:
  - NO! Chances are that as an active addict, you will fail in any attempt to treat your oral condition. Persons who are actively taking the drug or are still involved in the culture of addicts are unlikely to change the destructive lifestyle that caused the problem in the first place. Addicts are generally unable to maintain their oral hygiene or place restrictions on their sugar use. Unless they can control these aspects of their lives, all attempts to repair the damage are destined to failure. Addicts who kick the drug habit but maintain the lifestyle associated with it are likely to relapse and become addicted again.
- If you can successfully kick both the habit and the lifestyle:
  - YES! It is possible to treat Meth Mouth if you have truly decided to re-enter society. This means both kicking the drug habit and having enough self respect to follow through with your treatment! This entire website is dedicated to explaining how dentists repair situations like yours. Go to my index page and then click on the "Start Here" button. Caution! Here are the hard realities:
    - You MUST make and keep all your dental appointments. No dentist will maintain you as a patient if you don't. Addicts find this to be a major stumbling block.
    - You must maintain your oral hygiene and limit the amount of sugar you use, or all your dental work will rot out again.
    - Basic dentistry is available through state Medicaid providers, but for any of the more advanced treatments, you will have to seek out a private dentist. This costs money, and you will need to be gainfully employed or have some other means of making payments. No private dentist will treat you if you refuse to pay your bills.
    - The key is personal responsibility! If you are willing to take responsibility for the repair your ravaged mouth, you are on the road to the repair of your whole life.
Does Methamphetamine cause the rampant decay by itself?

There is speculation about the possibility that methamphetamine (the drug itself), directly produces the rampant decay seen in meth mouth. When in aqueous solution, it is somewhat caustic by itself. Several studies have shown that methamphetamine does lower saliva PH for a number of hours after the drug is ingested. (Click here to see one.)

I do not believe that low saliva PH or the the chemical causticity of methamphetamine contribute significantly to the decay. Note the distribution of the caries as shown in the image above. The decay tends to begin around the gingival margin (the gum line) and between the teeth. This suggests that the decay is associated with areas where plaque accumulates. Plaque causes this type of tooth decay when it becomes acidified as a result of frequent contact with sugar.

Low salivary ph caused by ingestion of methamphetamine would be more likely to cause hypocalcification over entire enamel surfaces (a bit like bulimia) rather than being limited to the distribution actually observed. Furthermore, I know of no research that has shown that plaque organisms produce excess acid in response to the presence of methamphetamine, or that corrosive levels of methamphetamine tend to accumulate in the plaque.

The pharmacologic activity of the drug produces dry mouth syndrome --lower saliva output. Dry mouth syndrome means increased decay as a result of a shift in the oral bacterial balance toward species that produce higher acid output when exposed to sugar. Considering the large amounts sugary soft drinks that addicts are prone to drink to satisfy their thirst, as well as the lifestyle that most addicts live, it is more likely that the drug's direct corrosive effect, and its effect on salivary PH are probably overwhelmed by the well documented destruction produced by the combination of poor oral hygiene, dry mouth, copious amounts of liquid sugar and bruxing.

P.S. Here is another image of what Meth can do to a human mouth. This one is from the site of the American Dental Society. I present it here to show the extent of neglect that the drug can produce: In the image above, the patient has brushed his own teeth. This shows the general condition of the teeth in the average addict.