A few years ago, I was a guest on a dental podcast discussing and fielding questions from the interviewer about the oral effects of methamphetamine. Prior to the “live” podcast, we had discussed questions in advance, which I thought I had adequately prepared for. But then came that moment, that pregnant pause, when I was asked a question, that stumped me, but not for the obvious reasons! The question was not difficult in terms of its embedded content but the question generated an emotional reaction within me. I knew that how I wanted to respond, “Is it really that simple” would not have been the most thoughtful or professional response. So instead, I responded by saying, “Gee, I wish I knew a little bit more about the patient before I recommended your suggested treatment plan”. By now, you are probably wondering what the question was.
“If a patient has ‘meth mouth’ and gross decay, shouldn’t we, as dentists, just pull out all their teeth, be done with it, and give them dentures”?
After the podcast, this question and my responses (both my internal response and external/professional response) nagged at me! The question reflected the frustration that we experience, as dental professionals, with patients whose teeth are blackened, broken and grossly decayed from their methamphetamine use. Trust me, I know! I have felt equally frustrated as I have watched my treatment fail, been disappointed by my patients’ relapses, and felt defeated while removing recurrent caries around my once beautiful restorative margins. But in my reflection, I realized that both of my responses are worthy of investigation and consideration.
“Is it really that simple”? No! Treating a patient with “meth mouth” is not a simple endeavor. The caries is blackened and advanced frequently into the pulp. There is a lot of smooth surface involvement with enamel that is so demineralized that finding sound enamel for a restorative margin can be difficult!
“Do we need to know more about the patient before we develop a treatment plan”? Yes! We cannot adequately care for our patients and propose an oral health solution when they have a significant mental health issue, such as a substance-use disorder, that will impact and potentially de-rail every aspect of treatment from lack of oral hygiene, to an acidic oral environment, to failed dental appointments!
In thinking more about this question, I realized that the best response, I could have given was this, “That is a great question! But we need to remember that the secret is not in the treatment but in our ability to plan treatment that takes into account our patient’s risk for caries due to their drug-use patterns”!
We need to understand about our patient’s drug history and ask leading questions. We need to establish preventive and restorative strategies and priorities before jumping into treatment that could unnecessarily edentulate our patients and even, on another extreme, create complex prosthetic treatment plans that have no chance of being successful!
This question, although it caught me off guard, allowed me to pause, reflect and realize that No, it is not that simple and Yes, we need to know much more about our patients!
In 2006, the California Dental Association, in collaboration with the University of California, San Francisco, School of Dentistry, developed a medical model for caries management by risk assessment called CAMBRA1. In this model, the successful management of caries requires that you first assess the patient for behavioral and clinical risk factors statistically related to caries management and then assign a patient a risk status (Low, Medium, High). It is only after this risk status is determined, that a treatment plan, targeted at the patient’s individual caries-risk level, can be developed.
Using this CAMBRA model, I developed the Meth Mouth Treatment Plan Assessment Form (MMTPA). This assessment is a modification of CAMBRA (Caries Management by Risk Assessment); a preventive approach to caries management, that utilizes chemical therapy, behavior change, and treatment modifications to create an individualized dental treatment plan for patients with a methamphetamine-use disorder.
We have to remember sometimes to pause, whether it is in response to an unexpected question, or before treating patients with “meth mouth”.
1Featherstone JDB, Alston PA, Chafee BW, Rechmann P. Caries management by risk assessment (CAMBRA)*: an update for use in clinical practice for patients aged 6 through adult. J Calif Dent Assoc. 2019;47(1):15-24. PMID:29355423.