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Ecstasy (MDMA) and Oral Health

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Ecstasy (MDMA) and Oral Health Ecstasy (MDMA) IN BRIEF • Ecstasy has a high frequency of oral side effects. PRACTICE • These oral effects are mainly related to and oral health xerostomia and jaw clenching. • Recent use of ecstasy may interfere with H. S. Brand,1 S. N. Dun2 and A. V. Nieuw Amerongen3 dental treatment. • Saliva can be used for non-invasive detection of ecstasy. VERIFIABLE CPD PAPER 3,4-methylenedioxymethamphetamine (MDMA), more commonly known as ‘ecstasy’ or XTC, is frequently used by young adults in the major cities. Therefore, it is likely that dentists might be confronted with individuals who use ecstasy. This review describes systemic and oral effects of ecstasy. Life-threatening complications include hyperthermia, hyponatraemia and liver failure. In addition, psychotic episodes, depression, panic disorders and impulsive behaviour have been reported. Oral effects include xerostomia, bruxism, and an increased risk of developing dental erosion. Mucosal changes have also been reported. Recent use of ecstasy may interfere with dental treatment. Finally, the potential use of saliva for non-inva­ sive detection of ecstasy is discussed. INTRODUCTION 3,4-methylenedioxymethamphetamine (MDMA, Fig. 1), more commonly referred to as ‘ecstasy’ or XTC, was patented in 1914 by the German pharmaceutical company Merck. Although MDMA is widely believed to have been synthesised as an anorectic, the actual patent does not make mention for such use.1,2 In the early 1960s, MDMA was rediscov­ ered by Alexander Shulgin. This chemist synthesised myristicin into MDMA by extracting it from the oils of nutmeg and mace, and distributed the MDMA among befriended psychotherapists. They would administer the drug to their patients therapeutically to increase self-insight, Fig. 1 Three dimensional structure of 3,4-methylenedioxymetamphetamine enhance empathy and help the patient through emotional blockages.1-3 as ‘ecstasy’, the drug was first used mainly contain varying amounts of MDMA In the late 1970s, illegal production of at home. From the 1980s, ecstasy became (typically 30-150 mg, on average 77 MDMA started in California (USA). Sold increasingly popular among hippies, mg) or none at all.5 Ecstasy tablets may yuppies and students. A major factor was also contain other substances, such the emergence of ‘house’ parties, and the as methylenedioxyethylamphetamine, 1*Department of Dental Basic Sciences, Section of Oral subsequent ‘rave’ scene. At ‘raves’, people methylenedioxyamphetamine, metham­ Biochemistry and Department of Oral-Maxillofacial would dance vigorously to the rhythmic phetamine, ketamine, caffeine and/or Surgery, Centre for Dentistry Amsterdam (ACTA), Am­ 5,6 sterdam, the Netherlands 2,3Department of Dental Basic beats and sounds of ‘techno’ music. Of salicylic acid. Sciences, Section of Oral Biochemistry subjects attending ‘raves’, approximately Ecstasy is frequently used in combina­ *Correspondence to: Dr H. S. Brand, ACTA, Medical Fac­ 4 ulty, room A-220, Vrije Universiteit, Van der Boechorst­ 90% report use of ecstasy. tion with alcohol or other types of drugs, straat 7, 1081 BT Amsterdam, The Netherlands which can result in unpredictable effects. Email: [email protected] Administration Ecstasy is usually combined with canna­ Refereed Paper Ecstasy is normally sold as tablets, bis (71%) or alcohol (66%). A combina­ Accepted November 2007 DOI: 10.1038/bdj.2008.4 which have different colours, shapes tion with amphetamine (29%) or cocaine ©British Dental Journal 2008; 204: 77-81 and logos (Fig. 2). Tablets sold as ecstasy (25%) is also frequently reported.7 BRITISH DENTAL JOURNAL VOLUME 204 NO. 2 JAN 26 2008 77 © 2008 Nature Publishing Group PRACTICE Ecstasy consumption In 1977, the United Kingdom Home Offi ce listed MDMA as a class A drug under the Misuse of Drugs Act of 1971.4 Despite its illegal status, use of MDMA is wide­ spread. The UK national criminal intelli­ gence service estimates that 0.5-2 million tablets are consumed weekly in Britain.5 Following a massive increase in the 1990s from 1% of the population in Eng­ land and Wales in 1994 to 2.2% in 2002, the annual prevalence rates of ecstasy had fallen to 1.6% by 2006.8 It is remark­ able that use of ecstasy is relatively high among British dental students (6-8%) and dentists (8-13%).9-11 Fig. 2 Ecstasy tablets have different colours, shapes and logos Mechanism and metabolism MDMA causes a massive synaptic release Although the general impression is The addiction risk of ecstasy seems of serotonin (5-hydroxytryptamine, 5- that ecstasy is a rather harmless drug, to be limited. Animal studies, however, HT) and, to a lesser extent, of dopamine it can have acute toxic effects. From suggest that long term use of ecstasy is and norepinephrine. Since MDMA also 1996 to 2002, 202 ecstasy-related deaths toxic to nerve cells.14 Recent evidence inhibits the reuptake transporters of the have been registered in England and suggests that serotonin-neurotoxicity synapse, there is an acute increase in the Wales, and ecstasy was apparently the may also occur with repeated MDMA use intra-synaptic concentration of these sole drug implicated in 17% of these in humans.21 This could explain the pro­ neurotransmitters, followed by a period deaths.15 The induced neuromuscular gressive memory deficits, observed in a of depletion.4,5 stimulation results in muscle rigidity group of 15 volunteers over a 12-month Following oral ingestion of an ecstasy and breakdown of muscle fi bres (rhab- period in which ecstasy was used at a tablet, the effects begin after 20 to 60 domyolysis). This degradation of muscle mean frequency of 2.4 times a month.4 minutes, peak after two hours and last tissue may raise the body temperature. four to six hours. The half-life of MDMA In combination with prolonged vigor- Oral aspects in plasma is six to nine hours. About ous dancing in hot and crowded clubs, Most oral effects of ecstasy that have 80% of MDMA is cleared metabolically this could lead to fulminant hyperther- been documented are case reports, in the liver, catalysed by the cytochrome mia with body temperatures as high as although the relation with xerostomia P450 isoenzyme CYP2D6. The remain­ 44°C.4,16 Fulminant hyperthermia has a and bruxism has been investigated more ing 20% of the dose is excreted unal­ poor prognosis, as it might lead to fur- systematically. tered in urine,12 in which MDMA can ther rhabdomyolysis, acute renal and still be detected two to three days after liver failure, and disseminated intravas- Xerostomia and dental erosion use. Ecstasy is also excreted in other cular coagulation.4,5,16-18 Therefore, it is In several studies 93-99% of the users body fluids such as tears, saliva, sweat important that victims with symptoms of experienced a dry mouth during an and breast milk.12,13 ecstasy intoxication are cooled as soon ecstasy induced trip.22-24 This xeros­ as possible.19 tomia can persist up to 48 hours after Mental and physical effects The combination of hyperthermia and consumption of ecstasy,14,24-26 especially Ecstasy has both physical and mental the warm environment of dance clubs in females.27 Although the incidence of effects (Table 1). For example, ecstasy results in an excessive water intake. dry mouth did not differ between one induces a euphoric feeling, suppresses However, ecstasy also stimulates the to three time users and individuals that tiredness, increases sensory perception secretion of antidiuretic hormone (ADH). used ecstasy multiple times,28 the risk and induces a sense of closeness to other This combination of increased water of acute xerostomia seems dose-related. people. Other symptoms are tachycardia, intake and impaired renal excretion will A dry mouth or throat was reported by tremor, dilated pupils, an increased body dilute body fluids, causing hyponatrae- 25% of healthy volunteers two hours temperature, nausea, suppressed appe­ mia and cerebral oedema with insults after administration of 0.5 mg MDMA/ tite, insomnia and restlessness. Some­ and coma.20 Therefore, consumption of kg, and by 88% after a dose of 1.5 mg/ times, body movements are diffi cult to isotonic fluids (such as sport drinks) kg. The xerostomia also persisted longer coordinate. Several days after use of instead of water is recommended, as after the higher dose.29 ecstasy, lack of energy, panic disorders, isotonic fluids will help to replace min- To relieve the xerostomia, hyper­ a depressive mood and diffi culty con­ erals and reduce the risk of developing thermia and dehydration from vigor­ centrating may be present.1,4,5,14 hyponatraemia.2 ous dancing, ecstasy use is associated 78 BRITISH DENTAL JOURNAL VOLUME 204 NO. 2 JAN 26 2008 © 2008 Nature Publishing Group PRACTICE Table 1 Mental and systemic effects associated with use of 3,4 methylenedioxymethamphetamine MDMA)5,32 Elevated mood Confusion Acute anxiety Panic disorder Depression Seizures Tremors Tics Nystagmus Hypertension Tachycardia Sweating Fig. 3 Mucosal fenestration of the attached gingiva of the 21 after local application of Urinary retention ecstasy (courtesy of W. J. Brazier) Renal failure they felt pain or tenderness in their Oral mucosa Acute liver failure jaw muscles.23 In an interview with 466 regular Nausea The clenching and grinding per­ ecstasy users, 2.3% reported that they Vomiting sisted for many hours after the ‘trip’. got mouth ulcers 24 hours later and Jaw clenching was still present after 24 8.2% 24-48 hours later.26 The mucosal Rhabdomyolysis hours in 19 to 40%.14,23,26,27 In one study, involvement is also illustrated by several Hyponatraemia 29% reported jaw clenching even after case reports. 26 32 Cerebral oedema 48 hours. Ecstasy had no gender effect Brazier and co-workers described a on the incidence of jaw clenching.27 case report of a 15-year-old boy with a Death Two studies suggest that larger doses of painful swelling of the maxillary labial ecstasy are related to more severe jaw vestibule (Fig.
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