Managing and Treating Patients with Meth Mouth

Thanks for joining us. I'm Dr. Phil Klein and this is the Dr. Phil Klein dental podcast. As dental professionals, regardless of where we practice, it is highly likely that we have patients that suffer from substance use disorders. Many of us are faced with cases where severe decay, hyposalivation, and poor plaque control may be the result of depressant, stimulant, or opioid misuse. Today we'll be discussing how to recognize the clues of a substance use disorder from a routine oral exam and talk about how we can deliver safe and effective dental care for these patients. Our guest is Dr. Ronnie Brown, a leading expert on substance use disorders and its oral effects. Her research on the impacts of drug use patterns on carrier severity has garnered international interest. She is a best-selling author, published researcher, and clinician. Dr. Brown practices at the Sonoma County Main Adult Detention Facility. Before we get started, I would like to mention that Dr. Brown's webinar titled Treating Between the Lines, Understanding Prescription and Illicit Drug Abuse is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Brown and you'll see the webinar. I highly recommend this to every office, especially with the rise in substance use disorders in our country. Dr. Brown, it's a pleasure to have you on the show. It's great to be here, Phil. Thank you. Yeah, and I want to point out to our audience that Dr. Brown's book, which by the way is getting great reviews on Amazon, the title of it is A State of Decay, Your Dental Guide to Understanding and Treating Meth Mouth. So the book offers step-by-step advice on how to recognize, communicate, and treat patients who have meth mouth. If this is something you're interested in learning more about, highly recommend the book. So that's really exciting that you have that book out. And it's amazing how much information I hear that's in that book. I have not read it, but I've heard great things about it. So tell us a bit about your background, which I think is very interesting. And how did you get started working at a medium security correctional facility? Great question, Phil. Clearly, when I was a dental student at UCLA, I never imagined that I'd be working in that type of environment. But as a dental student, I really enjoyed my dental public health courses and being able to go out into the community and deliver services to underserved populations. But, you know, when I graduated from dental school, I kind of followed the traditional path. I associated in private practice for a few years and then really. realized that I wasn't pursuing my passion. So I started to look for dental public health opportunities. And at that time, this was the late 1990s, there's no LinkedIn and online resources. So you would look at the local Sunday paper. And I saw an ad for a dentist at a medium security correctional facility. And I was curious. And I thought to myself, there's no way I'd ever work in that environment. But I'm curious. I made the call. The call led to an interview. The interview led to an offer. And that offer led to a decision that literally changed the trajectory of my career. And I've been working there for the last 26 years. Yeah, that was my question. How long have you been there? So you've been at the Sonoma County main adult detention facility for 26 years now. Yes. And that's remarkable. Now, who's in this detention facility? What kind of people are there? So it is a jail, and a jail is where people first go when they are arrested. So it's a wide range. The inmate population is both male and female. The variety and the severity of charges are pretty wide. broad, if you will, some very minor and some extremely serious. And so overall it's an unsentenced population, which means that they have not yet gone in front of a judge or jury to determine their guilt or innocence. If they are found innocent, obviously they are let go, if you will. If they are found guilty, then they are often transferred to prison where they then are sentence offenders serving a sentence. So you as a dentist in that facility, You're treating patients, but they may not be there that long, right? Correct. So the provision of dental services at the jail is primarily emergency and urgent focus, things that we can take care of that day. We're not providing comprehensive restorative care. So it's really addressing infection and addressing pain and also providing a lot of education because I think the population overall that I serve. is really lacking in terms of education, the impact of oral health, as well as the impacts on their systemic health. Okay, so it seems to me pretty obvious what happened while you were there for 26 years. You obviously saw patients, when they opened their mouth, you went, wow, this mouth is just full of decay, rampant decay, periodo disease, and the patient's probably 30 years old. A lot of these patients are not older patients, they're younger patients, right? Yeah. And that got you into understanding about substance use disorders. So let's move into that topic. How prevalent are substance use disorders and how likely is it for dentists in private practice to have patients with substance use disorders? Great question, Phil. Well, you know. When I started working at the jail in 1997, you know, as you indicated, I was seeing relatively young patients. And I really remember my very first patient was 20 years old. And when he opened his mouth, you know, very unprofessional, I gasped because I had never seen anything like this before. And initially I attributed what I was seeing to, you know, maybe, you know, high sugar diet, soda, candy. But when I kept seeing this pattern over and over and over again with my patients, and especially a very unusual pattern of decay, I realized I had to start asking my patients questions. And that's when I began to realize, based upon their responses, that what I was seeing was not the impact primarily of a sweetened diet. It was the impact of substance use disorders. Now, 26 years later, I'm definitely seeing the use and the prevalence of substance use disorders skyrocketing. 30% of my patient load in 1997 is now about 90% of my patient load in 2024. In 2021, according to the National Survey on Drug Use and Health, there were 46.3 million Americans that satisfy the criteria of a substance use disorder. And that's about one out of every 10 Americans. So if you think about those statistics, Phil, all you have to do is really look five to your right and five to your left, and there's somebody with a substance use disorder. It's highly likely that a dentist who's treating patients, regardless of his location, it doesn't really matter where he is. It could be a poor neighborhood or a higher economic neighborhood. It doesn't really matter because younger people that are using these drugs, it's kind of pervasive just about everywhere, is it not? Oh, absolutely. I mean, addiction is not a... a disease that is discriminatory. It's very indiscriminate. So it doesn't really matter about your zip code. It doesn't matter your socioeconomic status. It doesn't matter your level of education, your income, your gender, your race. It's an everybody anywhere problem. And the reality is this, Phil, before my patients became my patients, they were patients of somebody else in private practice or in community health clinics or in dental schools. The reality is this. We do have patients in our practices with substance use disorders, no different than we have patients in our practice with hypertension, with diabetes, with asthma. areas with periodontal disease. We all have these patients in our practices. With that said, how much of that percentage of people that you were talking about, what proportion are methamphetamine addicts? Where we typically have, you know, which were known as meth mouth, which is what your book is about. What are we looking at there proportionally? Yeah, great question. I'm not sure if I'm able to quantify it. But when I started working at the jail, that was the primary drug of abuse. And it continues to be. the primary drug abuse, but now we also have opioids. So in terms of what we're seeing statistically and pervasive here in this country, we're seeing opioids as the leading cause of drug overdose deaths in this country, methamphetamine being second to that. And we're also seeing an overlap of use between both of those drugs. So many patients are co-abusing those drugs and together that could be a very lethal combination because they wind up having opposing impacts. One's an upper, one's a downer. And oftentimes, they will try to reverse the effect of one drug by taking more of the other drug. And that's when patients get into very significant challenges. So when we talk about substance use disorders, for the most part, a very strong side effect or collateral damage is hyposalivation, is it not? Correct. And that is probably the culprit to a lot of the sequential... oral disease that follows this addiction can you talk about hyposalivation and then you know we can get into diet and poor oral hygiene of course that certainly doesn't help with that fundamental problem of hyposalivation we're just setting ourselves up for an environment that is just so conducive towards severe tooth decay Absolutely. I mean, hyposalivation is definitely one of the contributing factors, but there are also a number of behavioral factors as well. So in terms of the hyposalivation, Phil, the common denominator with any substance of abuse is that it causes pleasure. That pleasure principle or pleasure effect is due to the release of dopamine, a neurochemical that communicates a feeling of pleasure. But the challenge is that high levels of dopamine when released activates some receptors in the sympathetic nervous system that causes vasoconstriction of the salivary glands and so you have low salivary flow and we know that salivary dysfunction is a significant risk factor for caries but then you've got a number of other overlays and for example methamphetamine a drug that's highly acidic extremely corrosive. When that comes into the oral environment and then doesn't have the ability to be neutralized or buffered by the saliva, it's going to significantly lower the salivary pH and it'll drop it down to about 4.4. And we know that enamel begins to demineralize at a pH of 6.7. You then have with high levels of dopamine, you've got sugar cratings. And so you've got the impact of a sweetened diet. And when that's coming into the oral environment, once again, The sugar is being converted to acid without the ability for it to be neutralized and buffered. Then you have some behavioral issues. You've got, you know, oftentimes infrequent or the absence of daily oral hygiene. You've got a population now maybe due to financial resources that is no longer seeking preventive and maintenance services and oftentimes become absent as patients in our practice. And so that will further exacerbate what's happening in their oral environment. Yeah, and you summed that up very well. Now, I know this is probably in your book, but I'm going to ask it for our audience now because they may have not read your book. It's an uncomfortable discussion to have with a patient when they open their mouth and you recognize that there's something going on here, you know, especially in a younger person who has rampant decay. But it should be pretty clear to the clinician that there's a chance, high chance of substance use disorder associated with this rampant decay and gum disease, etc. How would you suggest the general practitioner to approach that conversation where they could proceed with the right treatment? And what is the right treatment at that point? Well, you know, great, great question. I think the conversation piece is probably the most challenging for practitioners because I think, you know, as individuals, we all have an emotional reaction to addiction. You know, we might know somebody who's addicted. We might have personal experiences with it. And so it becomes a very charged issue. And we also have a perception that nobody wants to talk about it. But the reality is that addiction is a disease of silence and people are suffering in silence. It is a very misconception that it does not want to be talked about. So one thing I can say about dental professionals is that we do talk about disease all day long. And if you frame your conversation understanding that addiction is a disease, it allows us to be very objective and neutral in our conversations. We always need to explain to our patients our why, why we're having this conversation. We want to help them. We want to deliver effective treatment plans. We want to keep them safe in our office. If you create and understand and articulate the why, it will help to misplace any perceptions the patient may have about. oh, I'm being accused or I'm being judged. You're saying, I really want to help you. I'm concerned and I care. And then utilizing motivational interviewing, you know, asking open-ended questions. Because, you know, the reality is this, Phil, when I started working at the jail, I had no idea what I was seeing. When I started to ask the question, you know, what are you putting in your mouth? And my patients would say, oh, I'm using methamphetamine. Once again, Phil, I had no idea what that was. I thought it was some type of weird nutritional supplement that they got from GNC, okay? So then I said very innocently, well, you had a lot to learn in that jail. Yeah, it was a lot to learn there. But remember, it's 1997, right? And so when I said, well, what's methamphetamine? And they told me what it was. And then I said, well, how do you use it? And they told me how they used it. How much does it cost? And they... As I was curious and honestly curious, they knew that I was coming out of a place of interest, of a place of concern, and they were able to open up. So my patients really became my first source of education on the topic. And then that led me to, by taking a look at what they were... what they were presenting with, hearing the conversations that we were having, I started to develop some hypotheses about specifically how they were using the drug that was driving the degree of carry severity. And that hypothesis led me when I went to get my master's degree to do a very large scale research topic on the subject of the impact of drug use patterns on carry severity. And I utilized my patient population at the Sonoma County Jail. As that source of, you know, population, both methamphetamine users as well as a controlled population. So I found a high degree of willingness in having these conversations. And I think if your patients know your why and that you express an honest curiosity and desire to help them, we can remove the stigma of silence that surrounds substance use disorders. We are capable. And we are required to have these conversations. So what did you find in your study? What were some of the findings? So we found that individuals who have a methamphetamine use disorder have significantly more teeth affected by decay than non-users. Now that finding was not... specific to our study. It had been reported previously, but it did help to corroborate that our research findings were consistent with published research. We then honed in on our population of methamphetamine users, and we found that within that population, there was varying degrees of severity. We had some patients had very little to no decay in their mouth, and other patients whose mouths were devastated by decay. So we began to investigate specifically how they were using the drug, and we looked at five drug use patterns. We looked at the amount they were using, the frequency, if they were co-abusing with alcohol, how many years they had used. as well as their primary route of administration. And we isolated two drug use patterns that were significant predictors of severity. One was duration of use. Those who reported using for more than 10 years had significantly more teeth that were decayed. And that really is kind of a dose response reaction, you know, longer exposure to a drug that's acidic. More likely you're going to have, you know, enamel demoralization, the salivary dysfunction that we talked about. But the second drug use pattern was the route of administration. Those who reported smoking methamphetamine had more teeth that were affected by decay than those who were bypassing the oral environment through snorting or injecting the drug. And I think intuitively that makes sense because when you're putting a drug that's so acidic and so corrosive into the oral environment, its impact on the salivary pH is significant. That's amazing that you did that research in the jail. I mean, what an opportunity that you took advantage of. which allows this information to get out there to the profession. So let me switch gears for a minute. Let's talk about the scenario where a patient sits down, a new patient, 25 years old, let's say. Patient opens their mouth and the dentist takes a look and is really completely shocked. Rampant decay, destroyed dentition. What is the best way for that dentist? to talk to that patient in the most professional and effective way and I'm sure the clinician has a good idea that there's some underlying cause for this other than just eating candy and most likely they're thinking substance abuse disorder. I think there's a variety of ways that you can approach it. And I think the first thing I want to, you know, make sure that I'm really clear about is oftentimes it's just not a one and done conversation. It's a conversation that hopefully will be something that kind of transpires over possibly multiple appointments. But if you're in that situation and it is going to be kind of a one and done, I would just say, you know what, you know, John, this pattern of decay is very similar. or very common with what I've seen in some other patients of mine who share with me that they have used methamphetamine. And my question to you, is that a drug that you have ever used? Now, the reason why I would frame it that way is, one, you're letting the patient know that you've seen this before. So you have some degree of experience, all right? You also have said... other patients that i have so you're letting the patient know they're not alone and then you said they shared it with me so that they felt comfortable enough to share that sensitive information with you and then you're just saying it looks very suggestive and you're expressing a degree of curiosity without accusing the patient so that might be one way to phrase it without um you know being accusatory but allows you to very quickly and succinctly let the patient know you've seen it before, you've got patients who shared it with you, that they're not alone, and then you can open up the door of communication. Now, even if that patient says no, you still want to document your suspicions. You know, what is it? Is it the color of the caries? Is it the location of the caries? Is it the patient's physical presentation? So I would still document it. And if that patient does present with a pattern of decay that is suggestive of a substance use disorder, that patient is automatically really flagged as a high risk patient. And you need to then incorporate into your treatment plan strategies that are appropriate for high risk patients. There's a lot of psychology, obviously, behind this. And I think your approach that you just mentioned, I'm sure it's covered in your book, is an excellent approach and a great way to develop a rapport with this patient. How do you get high compliance from the patient for home care when it got this bad? Isn't that a major challenge to get this patient to really care about their teeth as you start to restore them? Definitely a challenge because you're dealing with a lot of mitigating factors. But I think that you have to incorporate into the treatment plan. And hopefully when you're dealing with a high-risk patient, your treatment plan will be more simple versus complex because you are dealing with these mitigating factors. But you need to have the patient understand that they are an integral part of success and they are also an integral part of failure. And that clearly, as long as the substance use continues, the chance of failure also continues. They need to understand that what the impact is. So it's really sitting them down and having them have these real conversations about the acidity, the impact of saliva flow that they need to. And we sometimes have to be very practical in terms of maybe a harm reduction. If you're going to use, bring a toothbrush and floss with you. Because even though our goal always is abstinence, we also have to understand that may not be realistic for that patient. So we want to talk about what these are things that we can put in place to help mitigate some of these impacts. You know, remineralizing agents, getting you on a 5,000 part per million toothpaste, doing a fluoride treatment, utilizing silver diamine fluoride, shortening up our recall intervals. But you have to have these conversations. so that we're not setting up ourselves for failures as practitioners and our patients also setting up for failure in terms of disappointment. Are there any favorite products that you like for remineralization or anything in that area? Definitely have some of my favorites. I love Voco's Profluoride, which is 5% topical fluoride varnish. It's super easy to apply. It comes in a unidose packet that has the varnish plus the brush. So it's very well packaged. And then it has seven great flavors, I think ranging from traditional mint to exotic, you know, pina colada that patients can select from. But what I love about... Voco's product is that it's super easy to apply and then it contains xylitol so it helps to inhibit kerogenic bacteria and then you've got you know pretty high fluoride released within 40 minutes and you've got you know 5,000 part per million release within two hours so it really is a great product. I also as i mentioned really love glass ionomer and vocos ionostar plus is a restorative material that has fluoride release during its entire lifespan so when i use that as a direct restorative material i'm creating margins that are fairly carries resistance it also is very tolerant of moisture so i can place it subgingival and its handling properties are excellent it's syringable it's not sticky and then its aesthetics are really on par with some of our latest composites so those are probably some of my favorites So I'm curious, Dr. Brown, about your office over there in the prison, in the jail. Are you the only dentist working there? I am. I am the only dentist. Power to you. That's amazing. You've got a book out there that's doing great. The reviews were, like I said, I think there were like 4.6 or something out of five people were raving about the book. Oh, thank you. Yeah. Again, the name of the book is A State of Decay, Your Dental Guide to Understanding and Treating Meth Mouth. You certainly can't get this information from anybody more experienced in this field. than Dr. Brown based on her 26 years where she worked and the kind of patients she was seeing. I mean, this is where it all started. So Dr. Brown, thank you so much for your input. Really interesting podcast episode. I have never talked to a dentist who worked at a correctional facility before. So this is the first. So I'm really happy we got to talk to you and we hope to have you on the show again sometime in the future. Well, thank you, Phil. It's been a fantastic time spent with you and I look forward to having more conversations. if you like our podcast and want us to keep it going please leave a review on your favorite podcast platform leaving a review is a fantastic way to support us and help others discover our show we really appreciate your support see you on the next episode