GRISLY EFFECT OF ONE DRUG: 'METH MOUTH'

From the moment on Thursday when the young man sat down in Dr. Richard
Stein's dental chair in southwestern Kansas and opened his mouth, Dr. Stein
was certain he recognized the enemy. This had to be the work, he concluded,
of methamphetamine, a drug that is leaving its mark, especially in the
rural regions of the Midwest and the South, on families, crime rates,
economies, legislatures - and teeth.

Quite distinct from the oral damage done by other drugs, sugar and smoking,
methamphetamine seems to be taking a unique, and horrific, toll inside its
users' mouths. In short stretches of time, sometimes just months, a
perfectly healthy set of teeth can turn a grayish-brown, twist and begin to
fall out, and take on a peculiar texture less like that of hard enamel and
more like that of a piece of ripened fruit.

The condition, known to some as meth mouth, has been studied little in
dentistry's academic circles and is unknown to many dentists, whose
patients are increasingly focused on cosmetic issues: the bleaching and
perfect veneers of television's makeover shows. But other dentists,
especially those in the open, empty swaths of land where methamphetamine is
being manufactured in homemade laboratories, say they are seeing a growing
number of such cases.

These are the same towns, in some cases, that have wrestled in recent years
with shortages of dentists. They are places where dentists have struggled
to sell their practices as populations shrink; where new dentists have been
reluctant to settle, out of fear that they will not get enough business to
make ends meet; and where political leaders have offered financial
incentives to lure young dentists to town. For good or ill, meth mouth is
creating more business.

East of Dr. Stein's Dodge City office, in Independence, Kan., Dr. Cynthia
E. Sherwood said she too had seen such patients lately, including a woman
whose teeth had been transformed into "little black stubs" too painful to
brush and who wound up losing all her top teeth and six of her lower ones.
Among similar patients Dr. Charles Tatlock has seen in his New Mexico
office, he said, was one who, though only 17, needed dentures to replace
his suddenly decayed teeth.

And in Tennessee, Dr. Daniel D. Roberts gave up his ordinary practice not
long ago to handle a growing workload at 10 jails across the state, nearly
a third of whose prisoners, he estimates, have ravaged teeth owing to
methamphetamine.

"This is the worst thing to come along in a long time," Dr. Roberts said
the other day. "At this point, I'm digging for roots. That's how I make my
living."

Some dentists have their own hypotheses about precisely what causes the
condition.

Dr. John W. Shaner, an associate professor at the Creighton University
Medical Center School of Dentistry, in Omaha, said he believed that a
combination of factors tied to the use of methamphetamine led to such
enormous damage.

The drug itself, a synthetic stimulant that can be manufactured just about
anywhere, causes dry mouth, Dr. Shaner said, and that in turn allows decay
to start, since saliva is unavailable to help control bacteria in the
mouth. The drug also tends to leave users thirsty and craving a constant
supply of soda pop and other sugary drinks, which spur the decay; Mountain
Dew, he said, has become the preferred drink of methamphetamine users. At
the same time, the drug's highly addictive nature causes many users simply
to stop doing what is needed to take care of themselves, including the
brushing of teeth.

Other dentists said they suspected that the caustic ingredients of the drug
- - whether smoked, injected, snorted or eaten - contributed to the damage,
which tends to start near the gums and wander to the edges of teeth. Among
ingredients that can be used to make meth are red phosphorus found in the
strips on boxes of matches and lithium from car batteries.

There are also dentists who point to methamphetamine users' tendency to
grind and clench their teeth nervously, aggravating the frighteningly
twisted and tangled look of meth mouth.

If the man sitting in Dr. Stein's Kansas office on Thursday, who readily
admitted having used methamphetamine, gets all the work done that he needs
- - X-rays, fillings and crowns, and implants for the teeth now missing from
his mouth - he will require many visits, and the bill could run to as much
as $7,000.

Most dentists, though, say this is hardly the growth industry any of them
would wish for. The patients are grim, their teeth grimmer. Many of these
young people, the dentists say, may end up with no teeth at all but with
dentures, which some in dentistry had come to believe would soon be mostly
relics of the past, even for the elderly, in an age of water fluoridation
and other technology.

"The real market for dentistry is in saving teeth, in helping people have
dental health," said Dr. Stein, 57. "But I've seen a lot. I'm not a drug
counselor, and I'm long past lecturing, but this is a sorry situation."

Dr. Shaner said meth mouth might be little recognized in many places - even
as the drug has spread from one coast to the other and from rural areas
into cities - because methamphetamine is a problem that has had a chance to
sink in longer in places like Nebraska, Iowa and Missouri and because the
effects to teeth are often most obvious in pockets like prison populations.
He said he hoped to present information on the topic at a conference of the
American Dental Association next year.

With the exception of a few formal studies, including one now beginning in
New Mexico, meth mouth has so far been less a topic of academic analysis in
the dental profession than a matter for casual phone conversations and
e-mail exchanges between dentists in small places.

"The truth is, very little is known yet," said Dr. Stephen Wagner, who
specializes in dentures and implants in his private practice and who in
coming months will be studying 20 afflicted patients with Dr. Tatlock, an
assistant professor at the University of New Mexico. "What I can tell you
is what I have seen: It looks like someone has taken a hammer to these
teeth and shattered them."

One of the strangest truths of the condition, dentists said, is that
despite the truly grisly look, many patients do not report suffering from
as much pain as one would expect. Or at least, these dentists said, they do
not report such pain while still using methamphetamine.

Though the condition has begun turning up in private practices,
particularly in cases of emergency care and among recovering addicts, it is
far more prevalent in the dental offices of the nation's jails and prisons.

Local sheriffs in Midwestern and Southern counties have complained of
soaring dental costs in their jails. In North Dakota, more dentures have
been needed in the state penitentiary in the last few years, a development
that officials attribute at least in part to methamphetamine. In North
Carolina, dental workers in the Department of Correction learned about meth
mouth during a training session this month; starting in July, new prisoners
there will be screened for signs of dental problems connected to the drug.

In Minnesota's state corrections system, meanwhile, dentists' workloads are
so full of gruesome methamphetamine-related matters that they are strained
to get to other, less urgent cases: the routine cleanings and fillings of
years past.

"All of our time is getting eaten up," said Dr. Stephen Boesch, a dentist
who works at a Minnesota prison and who said he had begun to see the
problem in a juvenile corrections center as well. "We're seeing this week
in and week out."

Some dentists said they would never ask their patients about drug use; that
is not their place, they said. Others said they would ask, but could not
force the issue.

"That's the thing: you can't beat a confession from someone," said Dr. Eric
Curtis, who shares a practice with his father in Safford, Ariz., and began
seeing meth mouth four years ago.

"I suspect that many dentists are out there seeing this but don't know what
they're seeing," said Dr. Curtis, a spokesman for the Academy of General
Dentistry. "And most of them aren't going to know for sure."

The new business, he said, is actually a gloomy one for dentists in rural
places like Safford.

"What dentists really make the money on is the happy stuff: the low-impact
work with beautiful results," he said. "Nobody is happy when you pull a
bunch of teeth and put in dentures."