Page 16 - GP Spring 2024

The first article, titled ‘Association Be- paring the formulations, individuals using Each tablet takes 9 minutes to dissolve,
tween Sublingual Buprenorphine-Nalox- sublingual buprenorphine/naloxone were and the mean frequency of dose was 3.2
one Exposure and Dental Disease’, is a 1.42 times more likely to experience den- times daily. Poor bioavailability requires
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retrospective cohort study evaluating the tal adverse events than those using trans- the patient to hold the tablet sublingually
association between sublingual buprenor- dermal buprenorphine and 1.67 times more until dissolution. These factors may con-
phine/naloxone and dental adverse events. likely than those using oral naltrexone. In tribute to the alteration of the microbial
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This study employed the PharMetrics Da- summary, there appears to be an increased environment and the pH of the oral cavity.
tabase to recruit 21,404 users of sublingual risk of adverse dental outcomes with sub- Patients, however, also reported “cigarette
buprenorphine/naloxone, 5385 users of lingual buprenorphine/naloxone compared smoking, bruxism, regular soda consump-
transdermal buprenorphine, and 6616 users to transdermal buprenorphine and oral nal- tion, and moderate dental hygiene practic-
of oral naltrexone. The users were grouped trexone. es, as well as the use of other psychotropic
based on age, gender, and the comorbidities medications”, all of which may lead to
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they presented with. The inclusion criteria The study surmises that these results are dental adverse effects. Some of the limita-
limited the study to patients taking one due to the acidic nature of sublingual bu- tions of this study include a small sample
of the three study drugs with one year of prenorphine/naloxone. “Patients are in- size, which lends itself to the inability to
healthcare contact. The study excluded pa- structed to hold the tablet under the tongue relate the data to a larger population. Pa-
tients with previous use of the three study for 5 to 10 minutes to maximize absorp- tients reported confounding factors that
drugs in the prior year, opioid or alcohol tion. Thus, prolonged acidic exposure of may contribute to their dental disease.
use, illicit drug use, diabetes, or smoking. the drug in the mouth might lead to tooth The absence of a clear timeline indicating
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The rates of both dental caries or tooth loss damage.” Limitations of this study in- whether dental issues preceded or followed
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and dental adverse events, defined as any clude “lack of information on patient oral BPN usage introduces uncertainty into the
disease of the teeth, gums or pulp, were as- hygiene,” a large contributing factor to the data. Additionally, the study lacks a control
sessed in this study. manifestation of dental adverse events, car- group, and reliance on self-reported dental
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ies, and tooth loss. Additional limitations problems by patients further adds to the po-
The second article, titled ‘Sublingual Bu- include “possible unmeasured confound- tential for bias. 11
prenorphine and Dental Problems: A Case ing, capture of only dental events serious
Series,’ is a case series outlining patients’ enough to be reported to a physician, and Conclusions
experiences of worsening dental health. inability to fully ascertain the indication for The use of suboxone may have an anecdot-
This study provides insights into the den- the medication.” 10 al adverse effect on dental caries experi-
tal health of buprenorphine-treated indi- ence. Through examining the retrospective
viduals. The patient population included In ‘Sublingual Buprenorphine and Dental cohort study and the case series, it can be
Brigham and Women’s Hospital patients Problems: A Case Series,’ the results were inferred that the data is inconclusive. The
with opioid dependence. The inclusion as follows. From the initiation of treatment, acidity of buprenorphine, its prolonged ex-
criterion was worsening dental health “subjects reported a mean of 5.2 dental posure, and the alteration it causes to the
post-buprenorphine initiation. Patients re- caries (SD = 6.6; range, 0–24 caries), 3.6 oral flora may contribute to the caries risk.
cruited were on average 34.4 years old, dental fillings (SD = 8.8; range, 0–30 fill- However, patients may be prone to dental
predominantly white, on a mean buprenor- ings), 2.4 cracked teeth (SD = 1.6; range, decay due to personal habits and hygiene
phine duration of 45.7 months, a mean dai- 0–5 teeth), 0.9 crown placements (SD = practices consistent with opioid use/de-
ly dose of 11.6 mg, and a mean frequency 1.1; range, 0–3 placements), 0.8 root ca- pendence. Future recommendations for
of 3.2 times/day. The patients were mostly nal treatments (SD = 1.1; range, 0–3 treat- dentists include performing initial dental
prescribed buprenorphine/naloxone. 11 ments), and 0.7 tooth extractions (SD = assessments and caries risk assessments. It
0.8; range, 0–2 extractions). At the time would be prudent for dentists to create pre-
Results of the assessment, the majority of subjects ventive strategies for their patients, partic-
In ‘Association Between Sublingual Bu- (54.5%) reported having toothache pain. ” ularly scheduling regular dental examina-
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prenorphine-Naloxone Exposure and Den- Salivary buffering capacity was noted to be tions. Patients must also be counseled on
tal Disease,’ the following results were “low, moderate, and high in 54.5%, 36.4%, the importance of oral hygiene and good
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reported. Per 1000 person-years, dental and 9.1% of the patients, respectively.” In dietary habits to reduce their risk of devel-
caries or tooth loss rates were found to be summary, the majority reported tooth pain. oping dental disease and to take a proactive
8.2 for sublingual buprenorphine/nalox- Patients also reported having experienced role in their oral health. Patients must be
one, 3.5 for transdermal buprenorphine, caries, fillings, RCTs, crown placements, encouraged to strictly adhere to the pre-
and 3.8 for oral naltrexone. When com- cracked teeth, and extractions. More than scribed buprenorphine regimen to prevent
paring the formulations, individuals using half of the group presented with low sali- severe consequences such as relapse, mis-
sublingual buprenorphine/naloxone were vary buffering capacity. use, overdose, and potential fatality.
1.57 times more likely to experience den-
tal caries or tooth loss compared to those A discussion of the results led to the con- References:
using transdermal buprenorphine and 1.71 sideration of the effect of acids on tooth 1. Association AP. Diagnostic and Statisti-
times more likely compared to those using structure. A combination of the acidic na- cal Manual of Mental Disorders, 5th Edition
oral naltrexone. Per 1000 person-years, ture of the medication (having a pH of 3.4 - DSM-5. American Psychiatric Publishing;
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the dental adverse event rates were found when dissolved in water), salivary buffer- 2013.
2.https://www.fda.gov/drugs/informa-
to be 21.6 for sublingual buprenorphine/ ing capacity, and the prolonged period in tion-drug-class/information-about-medica-
naloxone, 12.2 for transdermal buprenor- which patients must allow the tablet to dis- tion-assisted-treatment-mat#:~:text=There%20
phine, and 10.9 for oral naltrexone. In com- solve may all contribute to dental decay. are%20three%20drugs%20approved,with%20
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