RESEARCH

Dental disease prevalence among

methamphetamine and heroin users
in an urban setting
A pilot study
Carolyn Brown, DDS; Sumathi Krishnan, MDS, MPH; Kevin Hursh, DDS; Michelle Yu, BA;
Paul Johnson, DDS, MS; Kimberly Page, MPH, PhD; Caroline H. Shiboski, DDS, MPH, PhD

onmedicinal or illicit

N
D

A B S T R A C T
A
methamphetamine J
A

use in the United ✷


✷

States is a serious Background. Researchers have reported rampant

N
CON

IO
public health concern owing caries among methamphetamine users. The authors

T
T

A
investigated the prevalence of dental disease and asso- N

I
to the drug’s high prevalence A
U
IN
G ED
U
C

ciated risk behaviors in methamphetamine users RT 3

of use, its addictive nature I C LE
and its putative effects on compared with those in heroin users.
long-term users. According to Methods. This pilot project was a cross-sectional study of an ongoing
the 2007 edition of the cohort of young adult injection-drug users (IDUs) in San Francisco. Par-
annual National Survey on ticipants completed an oral health questionnaire administered by a
Drug Use and Health research assistant, and dentists performed clinical examinations to
(NSDUH), approximately record the participants’ data in terms of scores on the decayed-missing-
5 percent of the U.S. popula- filled surfaces (DMFS) index, presence of residual roots, scores on an oral
tion 12 years or older—or 13 hygiene index and whether any salivary hypofunction was observed.
million Americans—had Results. The prevalence of dental disease among 58 young adult IDUs
was strikingly high compared with that in the U.S. general population;
reported ever having used
however, the authors found no difference in the level of dental disease
methamphetamine. 1
between users of methamphetamine and users of heroin. The mean
Researchers in the 2009
DMFS score and number of decayed surfaces exceeded 28 in both groups.
NSDUH reported a higher
Conclusions. Although the authors detected no difference in dental dis-
number of past-month
ease between methamphetamine and heroin users, they found a high
methamphetamine users,
prevalence of caries and caries-associated behaviors in the sample of
and a significantly higher young adult IDUs.
number of new methamphet- Clinical Implications. Given the high level of dental disease observed
amine users, in comparison in this population of young adult IDUs, one next step may be to explore
with the previous year.2 The the feasibility and effectiveness of providing low-intensity preventive
results of another national measures (such as distribution of chlorhexidine rinses or xylitol gum or
survey from 2008 suggested application of fluoride varnishes) through outreach workers.
an increase in reported Key Words. Methamphetamine; heroin; caries; drug abuse; oral health.
methamphetamine use in the JADA 2012;143(9):992-1001.
high school–aged population

Dr. Brown is the dental director, Programs and Development, San Francisco General Dental Department, Native American Health Center, San Francisco; and
assistant clinical professor, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco.
Dr. Krishnan was a research assistant, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, when this study was
conducted. She now lives in Bangalore, India.
Dr. Hursh is the clinical dental director, San Francisco General Dental Department, Native American Health Center, San Francisco; and an assistant clinical
professor, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco.
Ms. Yu is a statistician, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco.
Dr. Johnson was a student, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, when this study was conducted.
He now is a pediatric dentist at Smile Island, Rocklin, Calif.
Dr. Page is a professor in residence, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco.
Dr. Shiboski is a professor of oral medicine, Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, Box 0422, Room
S612, 513 Parnassus Ave., San Francisco, Calif. 94143-0422, e-mail caroline.shiboski@ucsf.edu. Address reprint requests to Dr. Shiboski.

992 JADA 143(9) http://jada.ada.org September 2012

Copyright © 2012 American Dental Association. All rights reserved.

in the United States.3,4 The percentages of U.S.
admissions to substance abuse treatment serv-
ices for primary methamphetamine or ampheta-
mine use more than doubled from 1996 to 2007,
from 3.3 percent to 7.5 percent. In California,
methamphetamine-related admissions
increased by 363 percent from 1992 to 2005.5
Investigators have uncovered an association
between illicit drug use and poor oral hygiene,
high sugar intake, alcohol use and tobacco use.6-9
Dependence on drugs also is associated with
severe social, financial and health conse-
quences.10 One of the many reported adverse
health effects noted with long-term methamphet-
amine use is severe dental caries, widely referred
to as “meth mouth” in the scientific literature
and in the press.11 First reported by Shaner12 in
1992, meth mouth is described as rampant
dental caries in a pattern specifically on buccal
and lingual surfaces and involving widespread
destruction of coronal tooth structure, often
appearing as residual root tips. Although this
atypical caries pattern in adults is speculated to
be specific to methamphetamine use, it also is
associated with hyposalivation secondary to radi-
ation treatment and was first reported as being
associated with prolonged heroin use and in poly-
drug users.7,13-15 In addition to this atypical caries
pattern, bruxism, attrition and trismus have
been reported among drug users, including
methamphetamine users.16
The etiology of dental caries secondary to pro-
longed drug use has been attributed to salivary
hypofunction, poor oral hygiene and high-
frequency consumption of refined carbohy-
drates.15 Methamphetamine use is thought to
stimulate inhibitory α2-adrenergic receptors via
the central nervous system, thus inhibiting
unstimulated salivary flow.17 However, although
multiple clinical case reports and public aware-
ness messages of meth mouth have been pub-
lished, few investigators have conducted epi-
demiologic studies to explore the relationship
between methamphetamine use and clinical
manifestation of secondary, atypical dental
caries or tooth-loss patterns in a population.
The results of observational studies have shown
higher caries rates in drug users than in non-
drug users and higher tooth-loss rates in
methamphetamine users than in nondrug
users.7,18 Shetty and colleagues18 reported a sta-
tistically significant association of missing teeth
with the use of injected (as compared with
smoked) methamphetamine. It is still not clear,
however, whether a high caries rate is a conse-
quence of any injection-drug use or is specific to
methamphetamine use, as the term “meth
Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
mouth” suggests. Authors of a 2010 systematic
review of methamphetamine use and dental dis-
ease emphasized the need for more definitive
epidemiologic studies.19 Therefore, we conducted
an exploratory pilot study to evaluate dental
disease prevalence and patterns, as well as
dental caries risk factors, among injection-drug
users (IDUs), comparing methamphetamine and
heroin users. The caries risk factors explored
included dietary practices, signs and symptoms
of salivary hypofunction, and measures of oral
hygiene. This pilot study also was meant to
assess the feasibility of recruiting a population
of IDUs and to determine how readily these
users can be categorized according to the types
of drugs they use.
METHODS
Study population. We recruited participants for
this cross-sectional pilot oral health study by
drawing a convenience sample from a larger
ongoing cohort study of young adult IDUs in a
clinic in the Tenderloin district in San Francisco.
Investigators at the University of California, San
Francisco (UCSF), designed this larger parent
cohort, called the U Find Out study, part 1 (UFO-
1), to screen young adult IDUs for participation in
prospective epidemiologic studies regarding
human immunodeficiency virus (HIV) and hepa-
titis B virus (HBV) and hepatitis C virus (HCV)
infections; 1,445 participants are enrolled in it.20
Inclusion criteria for UFO-1 included the fol-
lowing: age from 18 to 29 years at enrollment,
self-report of use of an illicit injection drug in the
preceding month, ability to speak English and
recruitment by means of street-outreach
methods. Participants who tested negatively for
HCV, HBV and HIV have been followed up every
three months as part of a substudy called U Find
Out, part 3a.21 We recruited participants for our
oral health pilot study from participants in the
UFO-3a study who were reporting for follow-up
visits for that study across a seven-week period in
the spring of 2007. Participants were recruited
and enrolled during a weekly three-hour session
in our Tenderloin district clinic. Eligibility criteria
were the same as those for participants in the
ABBREVIATION KEY. BZD: Benzodiazepine. DMFS:
Decayed-missing-filled surfaces. HBV: Hepatitis B
virus. HCV: Hepatitis C virus. HIV: Human immuno-
deficiency virus. IDUs: Injection-drug users.
NHANES: National Health and Nutrition Exami-
nation Survey. NSDUH: National Survey on Drug
Use and Health. S-OHI: Simplified Oral Hygiene
Index. UCSF: University of California, San Fran-
cisco. UFO-1: U Find Out study, part 1. UFO-3a:
U Find Out study, part 3a.
JADA 143(9) http://jada.ada.org September 2012 993
RESEARCH
BOX
Oral hygiene indexes used
in the study.
DEBRIS INDEX
d0: No debris is present
d1: Soft debris covers not more than one-third of the
tooth surface OR extrinsic stains without other debris,
regardless of surface area covered, are present
d2: Soft debris covers more than one-third, but not
more than two-thirds, of the exposed tooth surface
d3: Soft debris covers more than two-thirds of the
exposed tooth surface
CALCULUS INDEX
d0: No calculus is present
d1: Supragingival calculus covers not more than one-
third of the exposed tooth surface
d2: Supragingival calculus covers more than one-third
but not more than two-thirds of the exposed tooth
surface OR individual flecks of subgingival calculus
are present around the cervical portion of the tooth
d3: Supragingival calculus covers more than two-thirds
of the exposed tooth surface OR a continuous heavy
band of subgingival calculus is present around the
cervical portion of the tooth
SIMPLIFIED ORAL HYGIENE INDEX*
The Simplified Oral Hygiene Index (S-OHI) score is the sum
of the debris index and calculus index scores divided by 6.
Scores can range from 0 to 6. S-OHI scores can be
categorized further as follows:
dgood: score from 0 to 1.2;
dfair: score from 1.3 to 3.0;
dpoor: score from 3.1 to 6.0.
* Source: Greene and Vermillion.24
UFO-1 screening study. Participants in the oral
health study may have been older than 30 years
because they had enrolled in UFO-1 several years
earlier. This oral health study was approved by
the UCSF institutional review board.
Variables and measures. Data collection
for the pilot oral study involved participants’
completion of a standardized questionnaire,
administered by a trained dental student (P.J.),
which collected information on general oral
health, dietary habits, perception of dry mouth
(gauged according to the definition by Fox and
colleagues22) and oral hygiene practices, as well
as a comprehensive oral/dental examination
performed by two dentists (K.H. and C.H.S.).
The oral health examiners and the question-
naire administrator were masked as to the type
of drug each participant used and the partici-
pant’s sociodemographic information. The clin-
ical examination included a caries assessment
according to the decayed-missing-filled-surfaces
(DMFS) index.23 We used the Simplified Oral
Hygiene Index (S-OHI), developed by Greene
and Vermillion,24 to evaluate the presence of
dental plaque and overall oral hygiene. The
994 JADA 143(9) http://jada.ada.org September 2012
Copyright © 2012 American Dental Association. All rights reserved.
S-OHI includes both a debris index and a cal-
culus index used on six preselected tooth sur-
faces. The box shows the scoring for these
indexes.
One dentist (C.H.S.) trained the other dentist
(K.H.) in the use of the various oral health
indexes, and they performed a calibration exer-
cise for the caries component of the DMFS index
and the S-OHI with two participants. Interex-
aminer agreement was 80 percent or higher for
both the caries component and the S-OHI. Fur-
thermore, interexaminer variability for the
overall study likely was minimal because the
majority of oral examinations (74 percent) were
performed by the same dentist (K.H.).
We obtained nonoral health data from the
parent study protocols (UFO-1 for baseline char-
acteristics and UFO-3a for follow-up data). All
UFO data were collected by trained UFO study
personnel who used calibrated technique and
standardized survey instruments. The follow-up
data collected as part of UFO-3a usually were
collected on the same day as or within one week
of the collection of the oral health data.
Statistical analysis. We used the χ2 test to
compare a range of sociodemographic character-
istics of the participants in our study with those
of the broader UFO-3a cohort from which they
were recruited to assess whether our subsample
was representative of the broader cohort.
We summarized sample characteristics by
using proportions. We categorized participants
according to the injection drug they had used
predominantly or had injected the most times in
the preceding month. The group we termed
“Meth” consisted of users of predominantly
methamphetamine and the “Heroin” group con-
sisted of users of predominantly heroin. The
investigators in the UFO studies track cessation
and relapse among their participants, all of
whom are IDUs.24 The UFO survey instruments
used to capture drug-use patterns were
designed by the UFO studies group and have
been in use for more than 12 years. Unlike
drug-use surveys cited in other referenced
dental literature, the UFO survey does not
assess addiction severity as its main outcome,
but rather targets exposure to drugs, including
dose, frequency and duration of use. Longitu-
dinal data from the UFO studies reveal a high
correlation between the drug used most days at
baseline and the drug used most days at sub-
sequent visits, with a correlation coefficient r =
0.70 (P < .01).25 Therefore, the participant’s drug
of choice in the preceding month is a good indi-
cator of his or her drug of choice across time in
this study.

We used contingency table analyses and the
Fisher exact test to compare specific drug-use
characteristics, dietary practices, dry mouth
symptoms, measures of oral hygiene, reported
use of dental care in the previous year, catego-
rized DMFS index scores, number of decayed
surfaces and residual roots between meth and
heroin users. We computed the median and
range of the DMFS index, the number of
decayed surfaces, the number of residual roots
and S-OHI scores, and we also compared partici-
pants in the Meth and Heroin groups with
respect to these variables by using a Mann-
Whitney rank-sum test.
RESULTS
From April 17, 2007, through June 5, 2007, as
part of seven three-hour sessions, we recruited
61 participants at our clinic in the Tenderloin
district in San Francisco. We excluded from the
final analysis three participants who did not
complete the parent study follow-up question-
naire and, therefore, did not provide complete
data regarding their drug-use behavior. Among
the 58 participants with complete data, 17 (29
percent) reported methamphetamine to be their
most commonly used injection drug and 41 (71
percent) reported predominant heroin use in the
preceding month. This is consistent with the
pattern of drug use reported by participants in
the UFO-3a study, in which 31 percent reported
using methamphetamine most days.25 The
majority of participants among both meth and
heroin users were male (76 and 66 percent,
respectively), were white (53 and 88 percent)
and had graduated from high school (59 and 44
percent) (Table 1). The participants ranged in
age from 18 to 36 years, with 76 percent and 78
percent being younger than 30 years among
meth and heroin users, respectively. More than
one-third in either group reported not having
been housed the previous night. There was no
significant difference in sociodemographic char-
acteristics between users in the Meth and
Heroin groups except with respect to race, with
a higher proportion of whites among the heroin
users. A comparison of sociodemographic vari-
ables between the present subsample and the
larger cohort revealed no statistically signifi-
cant difference with respect to sex (P = .78), race
(P = .58) or education (P = .38), suggesting that
our subsample was representative of the larger
cohort.
A large proportion of participants in both
Meth and Heroin groups reported using a wide
variety of both other injection and noninjection
drug types in the past month (Table 2, page
Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
997). The main difference between the two
groups with respect to drug use was a much
higher proportion of use of speedball (heroin
and cocaine mixed together) (63 percent) and
benzodiazepine (BZD) pills (61 percent) among
heroin users compared with usage rates for
those drugs of 29 and 13 percent, respectively,
among meth users (P = .02 and P < .01, respec-
tively). All heroin users and 94 percent of meth
users were current tobacco smokers, with 63
percent of those in the Heroin group and 44 per-
cent of those in the Meth group smoking at least
one pack of cigarettes per day. One-half of the
participants reported having used injection
drugs for at least eight years and reported
having injected drugs, on average, two to three
times per day.
About one-half of meth users reported
drinking two or more glasses of fruit juice per
day and one-third (29 percent) reported drinking
five or more nondiet soft drinks per day, com-
pared with 24 percent and 5 percent, respec-
tively, of the heroin users (Table 3, page 998)
(P = .06 and P = .07, respectively). More than 40
percent of participants in both groups reported
having only one full meal (such as breakfast,
lunch or dinner) or less per day. Heroin users
reported snacking more frequently, with a snack
being defined as a small amount of food con-
sumed outside of regular meals; 40 percent of
heroin users snacked six or more times per day
compared with 24 percent of meth users. One-
third of meth users reported having “cotton
mouth” often or all the time, and 35 percent said
they needed to sip water to help them swallow
their food (Table 3). However, we found no statis-
tically significant difference with respect to xero-
stomia or clinician-observed signs of oral cavity
dryness between the two groups.
About one-half of the participants in each
group reported never or only occasionally
brushing their teeth (Table 3). Nearly one-third
(28 percent) of heroin users had poor oral
hygiene (with an S-OHI score higher than 3)
compared with none in the Meth group, and the
association between S-OHI score and type of
drug predominantly used was statistically sig-
nificant (P = .04). However, the median S-OHI
scores were 2.08 among meth users and 2.33
among heroin users, and the results of a non-
parametric test (rank-sum) did not reveal a sta-
tistically significant difference in the S-OHI
scores between the two groups (P = .37). Thus,
although a significantly higher proportion of
heroin users were categorized as having poor
oral hygiene, the median S-OHI score did not
differ significantly between the two groups.
JADA 143(9) http://jada.ada.org September 2012 995
RESEARCH

TABLE 1 caries, and 18 percent

Sociodemographic characteristics among 58 of meth users had
seven or more
injection-drug users, according to type of injection residual roots com-
drug used predominantly. pared with only 2 per-
CHARACTERISTIC NO. (%) OF USERS, ACCORDING TO DRUG P†
cent of heroin users
USED PREDOMINANTLY* (Table 4, page 999).
Methamphetamine Heroin (n = 41) The median DMFS in
(n = 17) both groups was
Race higher than 20, and
White 9 (53) 35 (88) the mean DMFS was
Native American 2 (12) 1 (3) 28.6 in the Meth
Latino 2 (12) 0 (0) .01 group and 29.9 in the
African American 1 (6) 0 (0) Heroin group. The
Asian 0 (0) 1 (3) median number of
Other or mixed 3 (18) 3 (8) decayed surfaces was
Age (Years) seven among meth
users and nine among
≈1.0
18-24 6 (35) 16 (39)
25-29 7 (41) 16 (39) heroin users, whereas
30 and older 4 (24) 9 (22) the mean number of
Sex decayed surfaces in
Male 13 (76) 27 (66) the two groups was
.40
Female 3 (18) 13 (32) 28.8 and 29.8, respec-
Transsexual 1 (6) 1 (2) tively, reflecting a
Education skewed distribution
No high school (fewer 1 (6) 8 (20) of the number of
than 9 years of decayed surfaces.
schooling)
Some high school 6 (35) 15 (37) .59 However, there was
High school graduate 8 (47) 13 (32)
no statistically signif-
Some college 2 (12) 5 (12)
icant difference
education between the two
Main Type of groups with respect
Accommodation in to DMFS, number of
Last Three Months decayed surfaces or
Housing‡ 10 (63) 20 (49) .68
number of residual
Street§ 6 (37) 19 (46)
roots. A high propor-
Detention¶ 0 (0) 2 (5)
tion of participants
Main Source of among both meth and
income in Last
Three Months heroin users reported
Job(s) 2 (14) 3 (7) having visited a den-
Government aid# 0 (0) 3 (7) tist in the preceding
.76 year (82 percent and
Family, friends or 0 (0) 2 (5)
partner 76 percent, respec-
Illegal source** 2 (14) 10 (24) tively). However,
Multiple sources 10 (71) 22 (54) none of the partici-
No income 0 (0) 1 (2) pants visited the
* Column count for each characteristic may not add up to total column count owing to missing values; Native American
column percentages may not add up to 100 owing to rounding.
† Derived from a two-sided Fisher exact test.
Health Center for
‡ “Housing” defined as own apartment, home of parents or relatives, home of friends, halfway house, dental care after their
foster home, group home, hotel, motel, boarding house or shelter. study visit, even
§ “Street” defined as squat, park, street, space under freeway, doorway or vehicle.
¶ “Detention” defined as incarceration in prison or juvenile hall. though all partici-
# Government aid included benefits received from the Social Security Supplemental Security Income pants were given a
program, Social Security Disability Insurance, U.S. Department of Veterans Affairs, welfare, food voucher for a dental
stamps, Aid to Families with Dependent Children or unemployment benefits.
** Illegal sources included panhandling, selling drugs, selling sex and stealing. examination, a pro-
phylaxis and urgent
About one-half of the participants in each dental care (such as extraction of residual roots
group had nine or more tooth surfaces with or unsalvageable teeth).

996 JADA 143(9) http://jada.ada.org September 2012

Copyright © 2012 American Dental Association. All rights reserved.
 RESEARCH

TABLE 2

Drug-use and cigarette-smoking characteristics among 58 injection-

drug users, according to type of injection drug used predominantly.
DRUG-USE CHARACTERISTIC USERS, ACCORDING TO DRUG USED PREDOMINANTLY* P†
Methamphetamine (n = 17) Heroin (n = 41)
Type of Other Drugs Used, No. (%)
Other injected drugs used in preceding 30 days
Cocaine 2 (12) 9 (22) .48
Crack 5 (31) 16 (41) .56
Speedballs (heroin and cocaine) 5 (29) 26 (63) .02
Goofballs (heroin and speed) 6 (35) 5 (12) .06
Other 1 (7) 3 (10) ≈ 1.00
Noninjected drugs used in preceding 30 days
Marijuana 10 (77) 19 (61) .49
Hallucinogens‡ 5 (29) 8 (20) .49
Ketamine, sildenafil citrate or “poppers”§ 2 (15) 1 (4) .23
Opioid pills 8 (50) 25 (61) .55
Benzodiazepine pills 2 (13) 25 (61) < .01
Noninjection crack 8 (53) 31 (79) .09
Noninjection powder cocaine 2 (13) 5 (13) ≈ 1.00
Alcohol 13 (76) 28 (68) .75
Cigarette Smoking, No. (%)
Current use 16 (94) 41 (100) .29
Number of cigarettes per day
< 20 9 (56) 15 (37)
20-30 6 (38) 23 (56)
> 30 1 (6) 3 (7) .35
Drug-Use History, Median (Range)
Years of injecting 9.4 (0.4-16) 8 (0.1-17) .68¶
No. of injections per day in preceding 30 days 2.0 (0-4) 2.5 (0-15) .40¶
No. of days injected drugs in preceding 30 days 7.5 (0-30) 20 (0-30) .25¶
* Column percentages do not add up to 100 because categories are not mutually exclusive.
† Derived from a two-sided Fisher exact test.
‡ Hallucinogens are a broad class of pharmacologic agents, including but not limited to lysergic acid diethylamide and mescaline.
§ “Poppers” are alkyl and amyl nitrites, used most commonly by means of insufflation.
¶ Derived from a Wilcoxon rank sum test.

DISCUSSION tically significant, likely due to the lack of power

In this sample of 58 young adult IDUs recruited
from a larger cohort in San Francisco, we found
no differences with respect to dental disease
between Meth and Heroin users. However, the
prevalence of dental disease in these poly drug
IDUs was strikingly high compared with that in
the U.S. general population, in which the mean
DMFS and number of decayed surfaces are esti-
mated to be 13.4 and 1.7, respectively, among
adults 20 to 34 years of age, according to the
1999-2004 National Health and Nutrition
Examination Survey (NHANES).26 The mean
DMFS and the mean number of decayed surfaces
exceeded 28 among members of both the Meth
and Heroin groups. There also was a high pro-
portion of participants with seven or more
residual roots (18 percent) among meth users
compared with 2 percent among heroin users
(P = .06). However, the difference was not statis-
to detect a difference in this small exploratory
study. Almost all of the study participants were
active smokers (57 of 58; 98 percent), with more
than one-half (58 percent) reporting they smoked
at least one pack a day. This is another strikingly
high result compared with data reported by the
Centers for Disease Control and Prevention,
Atlanta, between 2005 and 2010 that revealed
that 20 percent of adults aged 18 to 24 years and
22 percent of adults aged 25 to 44 years were cur-
rent smokers in the United States.27
Both meth users and heroin users reported
having used other types of both injection and
noninjection drugs at some point in the previous
month. This finding highlights the difficulty of
exploring outcomes such as dental disease in
relation to a single type of injection drug such
as methamphetamine. As described in the
Methods section, longitudinal data from UFO

JADA 143(9) http://jada.ada.org September 2012 997

Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH

TABLE 3

Dietary practices, xerostomia and oral hygiene among 58 injection-

drug users, according to type of injection drug used predominantly.
CHARACTERISTIC NO. (%) OF USERS, ACCORDING TO DRUG P†
USED PREDOMINANTLY*
Methamphetamine (n = 17) Heroin (n = 41)
Dietary Practices
Frequency of juice consumption, no. of glasses per day
0 7 (41) 14 (34) .06
1 2 (12) 17 (41)
2 or more 8 (47) 10 (24)
Frequency of nondiet soft drink consumption, no. of glasses per day
0 4 (24) 11 (27) .07
1 3 (18) 16 (39)
2-4 5 (29) 12 (29)
5 or more 5 (29) 2 (5)
Frequency of meal‡ consumption, no. of meals per day
0 1 (6) 2 (5) .74
1 6 (35) 18 (45)
2 6 (35) 15 (38)
3 or more 4 (24) 5 (13)
Frequency of snack§ consumption, no. of snacks per day
1-2 6 (35) 6 (15) .25
3-5 7 (41) 18 (45)
6 or more 4 (24) 16 (40)
Dry Mouth
Clinician-observed signs of oral cavity dryness
Absence of pooled saliva 1 (6) 7 (17) .42
Dry or sticky oral mucosa 5 (29) 16 (39) .49
Oral mucosa erythema or tongue papillary atrophy 3 (18) 15 (37) .16
Self-reported symptoms of dry mouth (xerostomia¶)
Need to sip on water or liquid to swallow food 6 (35) 22 (54) .25
Complaints of dryness while eating a meal 3 (18) 6 (15) ≈ 1.00
Difficulty in swallowing dry foods (such as crackers) 4 (24) 11 (27) ≈ 1.00
Perception of amount of saliva in the mouth
Too much 1 (6) 5 (12) .86
Too little 2 (12) 3 (7)
Didn’t notice 11 (65) 27 (66)
Not sure 3 (18) 6 (15)
Frequency of “cotton mouth”
Never 2 (13) 5 (12) .16
Sometimes 7 (44) 27 (66)
Often 4 (25) 7 (17)
All the time 1 (6) 2 (5)
Not sure 2 (13) 0 (0)
Oral Hygiene
Frequency of brushing
Never/Occasionally 9 (53) 19 (46) .13
Once per day 3 (18) 17 (41)
Twice per day or more 5 (29) 5 (12)
Simplified Oral Hygiene Index (S-OHI) Score#
Good (0.0-1.2) 2 (12) 4 (10) .04
Fair (1.3-3.0) 15 (88) 25 (63)
Poor (3.1-6.0) 0 (0) 11 (28)
* Column count for each characteristic may not add up to total column count owing to missing values; column percent may not add up to 100
owing to rounding.
† Derived from a two-sided Fisher exact test.
‡ A meal is defined as breakfast, lunch or dinner.
§ A snack is defined as a small amount of food consumed outside of regular meals.
¶ Symptoms of dry mouth as defined by Fox and colleagues.22
# A nonparametric (rank-sum) test did not reveal a statistically significant difference in the two groups’ S-OHI scores (P = .37).

998 JADA 143(9) http://jada.ada.org September 2012

Copyright © 2012 American Dental Association. All rights reserved.
 RESEARCH

studies reveal a high TABLE 4

correlation between Prevalence of decayed, missing and filled surfaces
the drug used most
days at baseline and (DMFS) and root caries among 58 injection-drug
the drug used most users, according to type of injection drug used
days at subsequent predominantly.
visits.25 Therefore,
the patient’s drug of DMFS AND DENTAL CARIES OUTCOMES NO. (%)* OF USERS, ACCORDING P†
TO DRUG USED PREDOMINANTLY*
choice in the pre-
Methamphetamine Heroin
ceding month was a (n = 17) (n = 41)
good indicator of the
Categorized Outcomes, No. (%)
drug of choice across
DMFS
time in this study.
0-8 4 (24) 9 (22) .14†
Using national data,
9-16 2 (12) 8 (20)
Lambert and col-
28 17-31 6 (35) 4 (10)
≥ 32
leagues found the
5 (29) 20 (49)
rate of methampheta-
Decayed surfaces
mine use in rural
0 2 (12) 5 (12) ≈ 1.00†
young adults to be
1-4 5 (29) 11 (27)
more than twice that
5-8 2 (12) 4 (10)
among their urban
≥9 8 (47) 21 (51)
counterparts. There-
Residual roots
fore, perhaps one way
0 9 (53) 25 (61) .06†
of limiting con-
1-2 4 (24) 5 (12)
founders such as
polydrug use when 3-6 1 (6) 10 (24)

exploring the effect of ≥7 3 (18) 1 (2)

methamphetamine Continuous Outcomes, Median (Range)

use on oral health DMFS
may be to recruit a Decayed surfaces
study population Residual roots
from a rural setting. * Column count for each characteristic may not add up to total column count owing to missing values;
Overall, the main column percentages may not add up to 100 owing to rounding.
† Derived from a two-sided Fisher exact test.
difference detected ‡ Derived from a rank-sum test.
between participants
in the Meth and Heroin groups was with respect
to the use of BZD pills. The higher prevalence of
BZD use among heroin users may be attributed
to a number of factors stemming from drug sub-
stitution, co-consumption or both. Researchers
have reported extramedicinal use of BZDs by
IDUs, both heroin and methamphetamine
users.29 Other researchers have reported con-
comitant use of BZDs by opioid addicts (both
drugs are depressants and dopamine stimu-
lants).30 A behavioral economics analysis report
suggested that supply-side economics also may
be a factor. Chalmers and colleagues31 reported
that heroin-dependent drug users with a hypo-
thetical fixed drug budget would substitute
pharmaceutical opioids, BZDs and methamphet-
amine when the hypothetical price of heroin
increased; however, the hypothetical substitu-
tion of other drugs among methamphetamine-
dependent drug users was weak when the theo-
retical price of methamphetamine increased.
The dietary practices assessed in this sample
21 (1-136) 22 (0-140) .79‡
7 (0-115) 9 (0-92) .84‡
0 (0-11) 0 (0-12) .53‡
revealed high consumption of nondiet soft
drinks and fruit juice, as well as frequent
snacking throughout the day, in both groups.
IDUs had both clinical signs and symptoms of
oral dryness, and they reported brushing their
teeth infrequently, regardless of which injection
drugs they used predominantly. All of these are
well-known risk behaviors for dental caries and
likely are explanatory factors for the high
prevalence of dental disease found in this popu-
lation. This is consistent with the results of
other studies in which investigators have
reported high prevalence of dental disease and
unmet dental needs (both patient-reported and
clinically assessed) among long-time IDUs.32,33
Reece7 also found higher rates of dental caries
among users of heroin, methadone, ampheta-
mine and cannabis than among study partici-
pants who did not use these drugs.
None of the 58 participants chose to make an
appointment for dental care at the Native
American Health Center in San Francisco after

JADA 143(9) http://jada.ada.org September 2012 999

Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
their examination and disclosure of their oral
health status; this was despite the participants’
high rates of caries and the presence of frac-
tured teeth and residual roots, and despite the
fact that each participant was given a voucher
to receive an examination, a dental prophylaxis
and urgent care if needed. This suggests that
active IDUs’ perceived dental care need may not
equate with their actual oral health status. It
also alludes to the challenges faced by public
health professionals and community leaders in
developing strategies to prevent and manage
dental disease effectively in this population
through effective preventive strategies. Also, cli-
nicians should consider all types of drug use
when they suspect that a patient has meth
mouth and should probe previous and present
substance use with their patients.
CONCLUSION
In this study, we were successful in recruiting
active and long-term users of methampheta-
mine and heroin for the purpose of investigating
oral disease. It is the first study to our knowl-
edge to involve the use of established oral
health clinical indexes by which trained dental
professionals, using calibrated technique, could
measure dental disease prevalence and covari-
ates in such a cohort. Furthermore, it provides
valuable information regarding the pattern and
variety of drug use among young adult IDUs in
an urban setting.
Lessons learned from this exploratory study
suggest that a large sample size, a more elabo-
rate sampling strategy and a study design such
as cohort-control, in which participants are
recruited according to their exposure or risk
factor, may be needed in future research to
explore the association between any specific
drug used and dental disease. This may require
consideration of patients living in rural settings,
where methamphetamine use may be more
prevalent or may be used exclusively. Mean-
while, given the high level of dental disease
observed in this population of IDUs, one next
step may be to explore the feasibility and effec-
tiveness of low-intensity preventive measures
for this population (for example, distribution of
chlorhexidine rinses or xylitol gum or applica-
tion of fluoride varnishes). Furthermore, pro-
viding oral health education and low-intensity
intervention at sites where drug users typically
receive public health services and enlisting the
help of outreach workers in these settings may
help encourage disenfranchised drug users to
accept selected strategies to prevent dental
disease. ■
1000 JADA 143(9) http://jada.ada.org September 2012
Copyright © 2012 American Dental Association. All rights reserved.
Disclosure. None of the authors reported any disclosures.
The study described in this article was supported by grant R03
DE14939 from the National Institute of Dental and Craniofacial
Research and grant R01 DA016017 from the National Institute on
Drug Abuse, National Institutes of Health, Bethesda, Md.
The authors acknowledge the ongoing participation of all the par-
ticipants in the U Find Out study, University of California, San
Francisco, whose involvement continues to help provide important
information to public health practitioners and researchers. They
express sincere appreciation to Jennifer Evans, Erin Aying, Anuhya
Uppula, Nicholas Ching, Rithika Mathias and Karina Alcala for their
help with this project.
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