Ecstasy Related Periodontitis & Mucosal Ulceration (PDF)

PRACTICE IN BRIEF MDMA or ’Ecstasy’ is widely used and popularly regarded as safe Systemic effects may include sudden death. Excessive thirst is quenched by the consumption of sugary carbonated drinks. Tooth surface loss and TMJ symptoms may result from tooth clenching and g...

PRACTICE IN BRIEF MDMA or ’Ecstasy’ is widely used and popularly regarded as safe Systemic effects may include sudden death. Excessive thirst is quenched by the consumption of sugary carbonated drinks. Tooth surface loss and TMJ symptoms may result from tooth clenching and grinding Ecstasy related periodontitis and mucosal ulceration — a case report W. J. Brazier,1 D. K. Dhariwal,2 D. W. Patton,3 and K. Bishop,4 Methylenedioxymethamphetamine (MDMA) more commonly known as ‘Ecstasy’ is a widely used recreational drug. The oral and systemic effects associated with its use have been well documented. This paper highlights a previously unreported complication of MDMA use on the oral mucosa. MDMA periodontitis is illustrated with a case report and the local oral and systemic effects of MDMA use outlined. M e t h y l e n e d i ox y m e t h a m p h e t a m i n e MDMA and other less addictive drugs such by demethylation primarily in the liver and (MDMA) is a 3,4-methylenedioxy ring sub- as Cannabis has been considered. brain, catalysed by cytochrome p450,5 stituted amphetamine which is more com- The systemic effects associated with the although up to 75% of the drug is eliminat- monly known by several names such as use of MDMA have been well documented ed unchanged via urinary excretion.2 ‘XTC’, ‘E’ and ‘Love Drug’.1 MDMA was first and are summarised in Table 1. Acute toxi- synthesized in 1914 for use in chemical city effects are not dose related nor in the Oral implications warfare, however it was not used therapeu- majority of cases are they caused by impu- The interactions of ‘Ecstasy’ with mono- tically until the early 1970s when psychol- rities in the tablets.3,4 Metabolism occurs amine oxidase inhibitors and tricyclic anti- ogists used it as a facilitating agent for psy- chotherapy.2 It is now a class A listed drug under the 1971 Misuse of Drugs Act. The Table 1 Systemic effects associated with the use of MDMA illegal use of MDMA has become wide- Psychiatric spread in Britain, popularised in the early 1990’s at ‘raves’. It is a sympathomimetic Agitation, delirium, panic disorder, flashbacks, paranoia, hallucination, depression, psychosis and suicidal ideation. stimulant which is taken orally, or occa- sionally injected intravenously, and causes Neurological a sense of euphoria, insomnia and sup- Ataxia, seizures, tremor, tics, nystagmus and cerebral haemorrhage presses appetite. It is relatively easy to Cardio-vascular obtain and fashionably regarded as a ‘safe’ Tachyarrythmias, hypertension, myocardial ischaemia / infarction, and ventricular ectopy drug despite serious medical sequelae Respiratory including death. Decriminalisation of Pulmonary hypertension and oedema Hepatorenal 1Senior House Officer in Oral and Maxillofacial Surgery, Renal failure, urinary retention, myoglobinuria, jaundice, hepatitis and hepatic failure necessitating liver 2Specialist Registrar in Oral and Maxillofacial Surgery, transplantation15 3Consultant in Oral and Maxillofacial Surgery, 4Consultant in Restorative Dentistry and Implantology, Maxillofacial Metabolic Unit, Morriston Hospital, Swansea, SA6 6NL,Wales Metabolic acidosis, hyponatraemia, hypoglycaemia, rhabdomyolysis, hyperthermia Correspondence and requests for offprints to: Miss D K Gastrointestinal Dhariwal, Maxillofacial Unit, Morriston Hospital, Swansea SA6 6NL, Wales Nausea, vomiting, anorexia, diarrhoea, ischaemic colitis E-mail: [email protected] Other Refereed Paper Disseminated intravascular coagulation (DIC), vasculitis, sexual dysfunction, seretonin syndrome, aplastic Received 13.05.02; Accepted 24.10.02 anaemia and death. © British Dental Journal 2003; 194: 197–199 BRITISH DENTAL JOURNAL VOLUME 194 NO. 4 FEBRUARY 22 2003 197 PRACTICE depressants, which may be prescribed in the management of TMJ pain and atypical facial pain, resemble a tyramine reaction. Selective serotonin reuptake inhibitor (SSRI) antidepressants are competitive inhibitors of MDMA hepatic metabolism at the debrisoquine hydroxylase (CYP2D6) enzyme stage5 and may potentiate the acute adverse effects of Ecstasy. Drug abusers show a tolerance to local anaesthetics and conscious sedation and Fig. 1 Clinical may require greater quantities of anaes- photograph of mucosal fenestration defect thetic agent to achieve pain free dental associated with UL1 treatment.1 (21) at the site of The oral effects of MDMA are a manifes- MDMA topical tation of the systemic effects of the drug. application Documented oral manifestations of MDMA use are summarised in Table 2. Dry mouth, relation to the upper central incisors. Both bruxism and jaw clenching are common maxillary central incisors exhibited Grade acute effects of MDMA use. The thirst may II mobility and were tender to percussion, be quenched by the consumption of sugary but were otherwise sound. Incision and carbonated drinks leading to extensive cer- drainage of the presumed acute dentoalve- vical caries and erosion. Thirst may also be olar abscess was performed and yielded quenched by excessive consumption of serous fluid which was sent for culture. water and self-induced water intoxication Routine blood tests were performed. Oral is recognised in patients with ecstasy poi- antibiotics, Penicillin V and Metronidazole soning. The Ecstasy induced trip may last were commenced. up to 36 hours such that tooth clenching Laboratory studies revealed a white cell and grinding is prolonged. The bruxism count (WCC) of 8.2 x 109/l [normal range and clenching may lead to muscle tender- 5–10 x 109/l], predominantly eosinophils. ness and stiffness and coupled with the The erythrocyte sedimentation rate (ESR) excessive consumption of acidic beverages, was elevated at 23 mm/hr [normal range tooth surface loss (TSL) is compounded.6–8 2–10 mm/hr] and hepatic enzymes aspar- tate transaminase (AST) and gamma glu- tamyl transferase (GGT) elevated at 59U/l Table 2 Oral manifestations of MDMA use and 43 U/l respectively [normal range AST Bruxism = 0–40 U/l; GGT = 0–85 U/l]. Microbiologi- Fig. 2 Upper anterior occlusal radiograph shows Tooth clenching cal culture yielded viridans streptococci, evidence of mild blunting of the roots of the teeth staphylococcus epidermidis and coryne- but no significant bone loss TMJ arthromyalgia bacterium species, consistent with com- Dental attrition mensal oral flora. Xerostomia On review 2 days later the swelling had sis of local drug induced necrotising gin- Mucosal ulceration reduced in size and systemic symptoms givitis was made. Periodontitis subsided. Mucosal fenestration of the Cessation of the use of MDMA was attached gingiva with exposure of the advised, and oral hygiene education provid- underlying alveolar bone and roots of the ed. Sub-gingival debridement and supra- This paper describes a complication of UL1 (21) and UL2 (22) was noted with gingival scaling of the involved teeth was MDMA use apparently not described previ- Grade II mobility of UR2 (12), UR1 (11), UL1 performed. Fluoride [Duraphat 2.26% Sodi- ously, occurring as the result of topical (21) and UL2 (22) (Fig. 1). The teeth were all um fluoride 5% varnish; Colgate] was also application of the drug. vital on electric and thermal pulp testing. applied to the exposed roots to relieve denti- Radiographic examination confirmed no nal sensitivity. An orthodontic retainer was CASE REPORT significant loss of bony support (Fig. 2). constructed to support the mobile upper A 15-year-old boy was referred to the Oral Detailed questioning in the presence of anterior teeth. The mucosal ulcer had healed and Maxillofacial Surgery Unit by his gen- his parents revealed no additional informa- at 1 week review and 4 months after presen- eral medical practitioner with a one day tion. The patient denied using any topical tation the teeth were firm and vital. The history of general malaise and pyrexia and agents in the area. patient at this time had no complaints, a painful upper anterior lip swelling. There He was referred to the dental hygienist although a 2–3 mm asymptomatic localised had been no history of trauma. The patient for oral hygiene instruction, scaling and defect of the alveolar gingivae and support- had completed 14 months of fixed appli- polishing. At this visit he reported that he ing bone remained, and he was discharged ance orthodontic treatment 4 months pre- had used ‘Ecstasy’ as a recreational drug back to his general dental practitioner for viously, and had a well maintained denti- one day prior to onset of symptoms and regular periodontal maintenance. tion with good oral hygiene. There were no stored the drug in the upper anterior pathological periodontal pockets, ie pocket labial vestibule adjacent to the site of DISCUSSION depths of 2–3 mm were noted. periodontal destruction. The patient MDMA is widely accepted within the gen- Clinical examination revealed a denied use of other recreational drugs eral population as a relatively safe drug swelling of the maxillary labial vestibule in and previous use of Ecstasy. The diagno- and is becoming more frequently used, 198 BRITISH DENTAL JOURNAL VOLUME 194 NO. 4 FEBRUARY 22 2003  PRACTICE despite its potentially serious side effects. attached labial mucosa such that pro- will encounter patients who abuse these These are not related to the dose or fre- longed contact with one area of epitheli- recreational drugs. This paper highlights quency of use. The malaise and fatigue um may not occur on the lip the need for a high index of suspicion of reported in this case is said to occur within Exposure to salivary flow — minor sali- drug abuse on presentation of unusual hours or days of MDMA use.9 The blood vary gland flow from the upper lip might periodontal conditions. biochemistry profile with mildly elevated wash away chemical irritants better than enzymes confirms a hepatitic picture con- alveolar mucosa 1. Rees T D. Oral effects of drug use. Crit Rev Oral Biol & Med 1992; 3: 163-184. sistent with MDMA use. The time interval Method of ecstasy application — if the 2. Shannon M. Methylenedioxymethamphetamine between drug use and onset of symptoms is tablet were held onto the alveolar (MDMA, ‘Ecstasy’) Paed Emer Care 2000; 16: 377-380. consistent with acute effects of MDMA. mucosa by the tip of the tongue whose 3. Wolff K, Hay A W M, Sherlock K et al. Contents of ‘Ecstasy’. Lancet 1995; 346: 1100-1101. There have been no previous reports of epithelium is more keratinised, this 4. Henry J A, Jeffreys K J, Dawling S. Toxicity and deaths oral mucosal or periodontal lesions associ- might not be affected and would shield from 3,4-methylenedioxymethamphetamine, ated with abuse of MDMA, although simi- the lip from the presumed chemical (“Ecstasy”). Lancet 1992; 340: 384-387. lar lesions to those seen in this case have burn. 5. Burgess C, O’Donohoe A, Gill M. Agony and ecstasy: a review of MDMA effects and toxicity. Eur Psychiatry been reported with the local application of 2000; 15: 287-294. cocaine. These include gingival and Parry et al.10 reported a case of a 6. Millosevic A, Agrawal N, Redfearn P J et al. The mucosal ulceration and periodontitis10–12 14-year-old multiple drug abuser who occurrence of toothwear in users of Ecstasy (3,4 MethyleneDioxyMethAmphetamine). Community which occur following chronic gingival applied cocaine and amphetamines onto Dent Oral Epidemiol 1999; 27: 283-287. application. This is thought to occur as a the upper labial vestibule and presented 7. Murray M C, Wilson N H F. Ecstasy related tooth wear. result of the ischaemic vasoconstricting with a clinical picture suggestive of Br Dent J 1998; 185: 264. action of the drug.12,13 Cervical abrasions necrotising gingivitis, with eythema and 8. Duxbury A J. Ecstasy — Dental implications. Br Dent J 1993; 175: 38. and gingival lacerations have also been ulceration of the gingiva adjacent to the 9. McCann U D, Slate S O, Ricaurte G A. Adverse described and are thought to be the result site of drug application. This was thought reactions with 3,4-methylenedioxymethamphetmine of excessive toothbrushing during a to be a local drug reaction caused by (MDMA: ‘Ecstsy’). Drug Saf 1996; 15: 107-115. 10. Parry J, Porter S, Scully C et al. Mucosal lesions due to ‘high’.14 This patient reported that he cocaine. However, the patient had also oral cocaine use. Br Dent J 1996; 180: 462-464. stored MDMA in the upper vestibule. This used MDMA in the same way but local 11. Lee C Y S, Mohammadi H, Dixon R A. Medical and was unusual as the drug is usually ingested effects of this drug were not considered. dental implications of cocaine abuse. J Oral Maxillofac Surg 1991; 49: 290-293. orally immediately, unlike cocaine which Juvenile periodontitis in an immunosup- 12. Yukna R A. Cocaine periodontitis. Int J Periodont when rubbed into the oral mucosa is well pressed patient can present with a similar Restor Dent 1991; 11: 73-79. absorbed. clinical picture but this explanation did 13. Gargiulo A V, Toto P D, Gargiulo A W. Cocaine induced The labial mucosa adjacent to the area not coincide with the clinical findings in gingival necrosis. Periodontal Case Rep 1985; 7: 44-45. 14. Friedlander A H, Gorelick D A. Dental management of of drug application was not affected. This this patient. the cocaine addict. Oral Surg, Oral Med, Oral Path might be due to : This case report highlights a previously 1988; 65: 45-48. unreported effect of MDMA abuse which 15. Garbino J, Henry J A, Mentha G et al. Ecstasy ingestion and fulminant hepatic failure: liver transplantation to Different mucosal types — the firmly may present to the general dental practi- be considered a last therapeutic option. Vet Human attached alveolar mucosa versus loosely tioner. It is increasingly likely that dentists Toxicol 2001; 43: 99-102. BRITISH DENTAL JOURNAL VOLUME 194 NO. 4 FEBRUARY 22 2003 199