Sir, reading the recent article on Ecstasy (MDMA) and oral health (BDJ 2008; 204: 77–81) reminded me of a case during my vocational training.

A 20-year-old female attended the dental practice complaining of 'flattened teeth' and a 'dry feeling in the mouth'. She also reported pain and stiffness of the jaw. Medically she was fit and well. She was a medical student and worked in a nightclub. She drank ten units of alcohol a week, smoked five cigarettes a day, and stated she did not use any recreational drugs.

Extra-oral examination revealed tenderness of the jaw joint and the muscles of mastication. Intra-orally, she had signs of a dry mouth, with frothy and airy saliva present. Clear saliva was expressible on palpation of her parotid glands. The patient had a class 1 molar and incisor relationship with canine guidance on lateral excursion. She had minimal restorations with fair oral hygiene. The premolars and molars showed signs of pathological toothwear. Radiographic examination revealed no abnormalities.

It was felt this patient suffered with TMJ pain dysfunction syndrome and xerostomia. The patient stated she was extremely stressed as exams were looming and she had relationship problems. I reassured her and gave conservative advice, and referred her to the local oral and maxillofacial unit for further assessment.

Following frequent consultations at the unit the patient eventually acknowledged a four year history of ecstasy, speed and cocaine use on a regular basis. The patient was diagnosed with xerostomia, toothwear and TMJ pain secondary to drug abuse. She was referred to the drugs and alcohol dependence unit for a rehabilitation programme.

This case illustrates that although an accurate and non-confrontational medical history was taken by several clinicians, the patient could only be managed fully when she was ready to reveal her drug use. Unfortunately, it took one year for the patient to acknowledge her habits therefore delaying diagnosis and treatment. However like most drug or alcohol dependents, she was able to reveal all when she felt comfortable within herself and the environment she was in, suggesting that along with a non-confrontational approach, frequent visits may be necessary to build trust and establish a good rapport with the patient.