Page 15 - GP Spring 2024

Beyond Substitution Therapy: Exploring the Impact of
Suboxone on Oral Health

Authors: Lana Kaleel, Gary Berkowitz DDS and Analia Veitz-Keenan, DDS, FAGD

Background gual buprenorphine/naloxone may have a communication “warning that dental
Opioid use disorder is defined as a “prob- played a role.” However, it must also be problems have been reported with med-
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lematic pattern of opioid use leading to considered that etiologic factors, including icines containing buprenorphine that are
clinically significant impairment or dis- “decreased attention to personal hygiene dissolved in the mouth. The dental prob-
tress.” The expression of this illness typ- [and] consumption of high-sugar beverages lems, including tooth decay, cavities, oral
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ically includes, “Compulsive, prolonged and food,” can result in dental disease, and infections, and loss of teeth, can be serious
self-administration of opioid substances these habits have been associated with pa- and have been reported even in patients
that are used for no legitimate medical tients who suffer from opioid dependence. 6 with no history of dental issues. Despite
purpose.” A patient is considered to be on these risks, buprenorphine seems to be an
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maintenance therapy if they are taking any A brief examination of a systematic review important treatment option for opioid use
of the three FDA-approved medications to of the literature on the relationship between disorder (OUD) and pain, and the benefits
treat opioid use disorder: buprenorphine, methadone and dental caries revealed that of these medicines clearly outweigh the
methadone, and naltrexone. 2 the sugar content in methadone is just one risks.” 9
of many risk factors that might contribute
Substitution maintenance therapy utilizes to tooth decay. In this review, “all papers, A quick search into the literature on this
medications like buprenorphine and meth- related to methadone and dental caries and matter led to the discovery of a case report
adone to replace potent opioids. Buprenor- available in English language, were includ- on the use of buprenorphine/naloxone and
phine functions as a partial agonist at the ed for review.” However, only three stud- dental caries, which revealed the following
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mu receptor. This quality lends itself to ies out of the nineteen were quantitative, findings in a patient. The patient had a one-
“many unique properties, specifically that forcing the reviewers to conduct a narrative year history of opioid dependence when
its analgesic effects plateau at higher doses, review of the literature. The data reveals she was placed on 8 mg BPN/N twice a
and then its effects become antagonistic. that there is a lack of conclusive evidence day. The patient reported a minimal history
Buprenorphine exhibits ceiling effects on establishing a definitive link between sug- of dental issues in the past, limited to small
respiratory depression, which means that it ar-containing methadone and dental caries. restorations on lower molars. The patient
is safer than methadone for agonist substi- Eleven studies implicate sugar-containing denied alteration of dental hygiene, report-
tution treatment in addiction.” Methadone, methadone in dental decay, with reports in- ing daily brushing, flossing, and regular
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a full agonist at the mu receptor, “can cause dicating similar decay experiences before dental cleanings. Similarly, the alteration
CNS depression and respiratory compro- and after methadone use. Dry mouth’s pos- of diet was also reported by the patient to
mise; hence it should be used with extreme itive link to sugar-containing methadone be insignificant, with similar consumption
caution in patients with CNS-related pa- is supported by five articles; however, the of cariogenic foods before and after the es-
thologies.” Though buprenorphine seems causative role of dry mouth in dental car- tablishment of BPN/N therapy. A routine
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to be the safer medication, methadone may ies is questioned. Comorbidities such as dental visit revealed extensive decay in
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be preferred due to its lower cost. Both antidepressants represent a confounding the patient and the need for four root canal
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medications alleviate cravings for opioid variable, as medications to treat comorbid treatments on the patient’s molars. This re-
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use, and this therapy essentially involves conditions may result in the development view aimed to find evidence for the associ-
substituting opioids with substances like of dry mouth. Sugar-containing methadone ation between suboxone, or buprenorphine/
buprenorphine or methadone. The medi- and its prolonged contact time were also naloxone, and dental disease.
cations will be gradually tapered down to examined. Although methadone itself has
make the withdrawal process more com- minimal sugar content, equivalent to half Methodology
fortable. a teaspoon, its association with height- The search looked at the effect of subox-
ened sugar cravings and changes in dietary one, or buprenorphine/naloxone, on the
The need for insight into the effects of habits is noted. The direct contribution of manifestation of dental problems. The
drugs used for substitution therapy on oral methadone therapy to these dietary chang- search was based on the following clini-
health was introduced by anecdotal patient es remains uncertain based on current evi- cal question: in patients undergoing dental
reports of worsening oral health after the dence. 5 treatment, does the use of suboxone cor-
initiation of these medications. “The first relate with adverse effects on dental health
report on a correlation between sugar-con- Suboxone is a sugar-free alternative to compared to those not taking suboxone?
taining methadone and dental caries was methadone, with a specific formulation The database utilized in this search was
published in 1978. Patients reported that comprising a 4:1 ratio of buprenorphine PubMed, with keywords used in the search:
methadone was the cause of their dental to naloxone. Naloxone in this formulation “(suboxone) OR (buprenorphine) AND
caries.” Similarly, a “patient’s experi- “is [poorly absorbed] in the gastrointestinal (dental disease)”. A timeline was delineat-
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ence [detailed in a case report] of a sud- tract, [thus] it has very little effect when ed: articles published within 15 years. 99
den decline in her oral health without any properly taken… it has the ability to block results were filtered based on publication
changes in her dental hygiene practices or the effects of the buprenorphine when date and relevance, leading to two relevant
sugary food/beverage consumption raises crushed to be snorted and for injection articles.
the possibility that chronic use of sublin- abuse.” In January 2022, the FDA released
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www.nysagd.org l Spring 2024 l GP 15