REVIEW
Australian Dental Journal 2002;47:(2):94-98
Impact of opioid use on dentistry
A Titsas,* MM Ferguson†
Abstract
The oral consequences of opioid drug use are
commonly attributed to personal neglect of general
health and financial constraint. These factors are
compounded by the increasingly recognized range of
physical effects exerted by opioid drugs. The dental
management of opioid drug dependents is further
complicated by a variety of infections and
behavioural modifications commonly associated
with opioid use. Adequate strategies for the oral care
of opioid users need to take cognisance of the broad
medical issues for these people along with an
appropriate personal approach.
Key words: Opioid, methadone, morphine, tooth,
infection.
(Accepted for publication 17 August 2001.)
INTRODUCTION
The term opioid is an all-inclusive grouping of
synthetic and naturally occurring peptide drugs that act
on various membrane-bound receptors to produce
morphine-like effects. It has replaced the term opiates,
which is now reserved to describe alkaloids derived
naturally from the opium poppy (Papaver somniferum).
Opioid drugs bind to the various physiological
receptors recognized by endogenous opioid peptides,
such as enkephalins, endorphins and dynorphins.
Although three main classes of receptor have been
identified and cloned, i.e.: mu (m ); kappa (k); delta (d),
other receptor types exist which have not been as well
characterized.1
The primary incentives for opioid use are its ability
to induce a state of euphoria as well as mental detach-
ment. These effects are primarily mediated by the m
receptors that are also largely responsible for the
development of tolerance and addiction with repeated
opioid use.2 Table 1 lists the principal opioids used,
with patterns of their abuse varying from country to
country according to local availability and demand.2
Side effects with opioid drug use are common and
include nausea, vomiting, and constipation together
with the risk of hypotension and respiratory depression.
*General Practitioner, Alexandra, New Zealand.
†Professor of Oral Medicine and Oral Surgery, University of Otago,
New Zealand.
94
Should a drug dependent suddenly terminate the use of
a strong opioid, they may precipitate a withdrawal
syndrome characterized initially by restlessness,
anxiety, insomnia, sweating, lacrimation, rhinorrhoea
and craving for the drug. Such withdrawal signs usually
commence within about six hours of abstinence, before
reaching a peak between 36 to 72 hours and then
subside over one to two weeks. However, there may be
residual craving for the drug, insomnia, anxiety and
depression for many months and even years after the
cessation of opioid intake.2
Recent data indicate that approximately 2 per cent of
all Australians have tried heroin, with the highest
incidence of use occurring in young adult males
between the ages of 25 and 39 years. In females, the 14
to 24 year old group has the highest frequency of use.3
The pattern is similar in New Zealand where 3 per cent
of people between the ages of 15 and 45 years have
tried drugs for non-medicinal purposes. Again, such use
is most prevalent in young adult males.4
For the past 25 years, national protocols have been
established throughout Australasia for the management
of opioid dependency with the opioid substitute,
methadone.5 Currently, there are approximately 15 000
individuals in Australia and about 1300 individuals in
New Zealand participating in such methadone
programmes.6,7 Methadone is a synthetic, potent opioid
agonist drug prescribed for the treatment of opioid-
dependent injecting drug users. Being an orally
administered drug, daily methadone obviates the need
to use injectable narcotics, while its long half-life
prevents the occurrence of withdrawal symptoms. The
primary aim of such therapy is to achieve a transition
from methadone maintenance into a drug-free lifestyle
in a manner designed to minimize relapse and the
consequences of injecting narcotics. However, not all
patients can be weaned off methadone due to the
chronic and relapsing nature of established opioid
dependence. As such, secondary goals of life-long
methadone maintenance include encouraging opioid
dependents to attend treatment clinics, reducing deaths
and diseases linked with injecting drugs, improving the
dependents’ ability to function socially, as well as
lowering crime and social costs associated with illicit
drug use.8,9 Based on evidence attributing a reduced
mortality associated with opioid use to methadone
Australian Dental Journal 2002;47:2.
Table 1. Opioids commonly abused
Buprenorphine Methadone
Dextropropoxyphene Morphine
Diamorphine (heroin) Oxycodone
Dihydrocodeine Pentazocine
Dipipanone Pethidine (meperidine)
programmes,8 there is general acceptance of methadone
as a successful means of management for those unable
or unwilling to control their dependence. Nonetheless,
methadone users suffer from several undesirable side
effects. Alternate medications to methadone are being
evaluated for substitution regimes to overcome these
limitations including buprenorphine, 1-alpha-acetyl-
methadol and naltrexone.10
Medical problems
Individuals dependent upon opioid drugs are
vulnerable to a number of medical problems that are
multi-factorial in aetiology.
In an attempt to cope with a poorly controlled
psychological disorder, an individual may resort to the
use of opioid drugs. Often, in such cases, the pre-
existing disorder is accentuated rather than tempered
by the use of opioid drugs.11 Conversely, the habitual
use of opioids can itself precipitate the development of
a psychological disorder other than drug
dependency.12,13 Despite there not appearing to be a
standard psychological profile of drug dependents or
those likely to become dependent, clinical depression is
significantly more prevalent amongst opioid users than
it is in the non-opioid using population.14 Due to the
limitations of retrospective analysis, it is difficult to
determine in which cases the depression preceded the
drug use and in which cases initial drug use gave rise to
depression.
Commonly associated with opioid dependency are
significant changes in social behaviour. Even though
these changes appear to be closely related with apathy
and financial constraint, it should be borne in mind
that not all drug users are in the lower economic groups
and that they may lead an apparently normal lifestyle.
The neglect of personal care is a frequently observed
behaviour amongst opioid users, irrespective of
economic status.13 Accordingly, opioid users tend to
seek treatment only when the disease is advanced and
the symptoms become severe.15 Such late-presenting
patients with severe symptoms may be anxious and
demanding, consequently making their management
considerably more challenging. The altered social
behaviour of drug users often leads to increased sexual
activity without the use of precautionary measures.
Such unsafe practices generally occur during periods of
euphoria when users become more promiscuous as well
as during prostitution, which drug dependents may
resort to for necessary income.16 Opioid users also
demonstrate a propensity to be exposed to violent
situations, which may be responsible for the higher
rates of trauma experienced by these individuals.17
Australian Dental Journal 2002;47:2.
Opioid users are highly susceptible to a variety of
infections. Such common infections include HIV, viral
hepatitis18,19 and infective endocarditis,20 all of which
have significance in a dental setting. This increased
propensity towards infection can be attributed to the
sharing of contaminated needles, an increased
participation in unsafe sexual activity and a reduced
immune competence. The significance of immuno-
suppression in these patients is clearly demonstrated by
the fact that opioid users can contract infective
endocarditis on a previously uncompromised
endocardium.20 Although factors associated with drug
use, such as alcoholism,8 dietary deficiency21 and
general personal neglect can all adversely affect the
immune system, there is a growing body of evidence
that certain opioid drugs are capable of directly
suppressing aspects of immunity. Such direct opioid
effects on immune function include a lowering of the
total lymphocyte count, a depression in the CD4:CD8
lymphocyte ratio, a reduction in immunoglobulin and
tumour necrosis factor production and suppression of
natural killer (NK) cell activity.22 It appears as though
the immunological deficits seen during opioid
consumption are reversible after several years of total
opioid abstinence.22 The mechanisms responsible for
these opioid-induced changes remain unclear although
surface opioid receptors have been identified on various
leukocytes.
In light of the range and prevalence of disease in
opioid dependents, all patients entering into a
methadone programme undergo a thorough medical
and psychological assessment and, as part of their
initial evaluation, are screened for the above disorders
and infections.23 Individual responses to medical
treatment vary considerably but those who take a
greater interest in their own welfare often respond well
to therapy.24
Oral conditions
Opioid dependents are susceptible to a variety of oral
diseases, not least of which are dental caries and
periodontitis. Despite the frequent citation in the
literature of various conditions affecting these patients,
the underlying pathogenic mechanisms are only
recently being better understood.
High rates of generalized dental caries, being
particularly prevalent on smooth and cervical surfaces,
have been widely described in opioid users.25-27 There is
a growing body of evidence to suggest that this high
prevalence of caries is due to a complex, dynamic
relationship between multiple factors. General personal
neglect combined with a shortage of money may lead
an opioid user to consume a diet made up largely of
convenience foods high in simple sugars. The ingestive
behaviour of opioid users is also directly modulated by
central opioid receptors, most probably the k and m
receptors.28 Such modulation includes the mediation of
the increased palatability and rewarding aspects of
sweet substances experienced by opioid users.29 This
95
opioid-induced taste preference for sucrose can be
reversed in mice with the administration of the
antagonist naltrexone. Consequently, the ability of
opioids to directly induce a heightened craving for
sweet carbohydrates15,30,31 may be a significant
contributing factor to the consumption of a diet rich in
simple sugars.
Any concomitant altered self-image, depression
and/or lack of motivation will likely result in lowered
standards of oral hygiene. The impact of poor oral
hygiene and an altered taste preference for sweet foods
on the development of carious lesions is compounded
by the xerostomic effects of opioid and medicinal
drugs. While it is well established that opioids,
including methadone, reduce pancreatic, biliary and
gastric secretion, it is not widely recognized that
opioids can also result in xerostomia.1,32 Opioid induced
xerostomia does not appear universally to be of a
severe magnitude on its own but the concomitant use of
antidepressants33 may accentuate this condition.
Although there are no studies seeking to demonstrate
certain microbial profiles specific for opioid addicts,
altered microbial populations are known to exist in
patients with salivary gland hypo-function. Such
alterations may render the plaque more cariogenic,
particularly in an environment of readily available
sugars. Other problems of chronic salivary hypo-
function include a dry or burning mouth, taste
impairment, eating difficulties, mucosal infections and
periodontal disease.
The frequent intake and prolonged retention of
sucrose-syrup-based oral methadone preparations is
possibly another potentiating factor in the progression
of dental caries in methadone patients.34 Methadone
patients may adopt a habit of retaining this syrup in
their mouths for long periods of time in order to
prolong the absorption time or to enable later
degurgitation for sale or parenteral administration. To
negate these detrimental effects, sorbitol is being
substituted for sucrose to render methadone
preparations sugar-free, as well as methylcellulose or
gum tragacanth being added to render the preparation
less cariogenic and more difficult to inject,
respectively.26,34
Once established, any pain arising from dental
lesions may be masked and/or ignored due to the
analgesic and mental detachment effects of opioids,
respectively. Accordingly, help may be sought only for
extreme pain, which may account for the observed high
prevalence of dental caries when addicts first present to
a dentist.25,27
Periodontal disease is also frequently seen in drug
dependents. The pattern is typically one of adult
periodontitis, although acute necrotizing gingivitis has
also been reported.35,36 It seems that the effects on the
periodontium due to a high rate of plaque
accumulation, resulting from neglect and xerostomia,
may be exacerbated by the immuno-suppressive effects
of opioids and potentially altered microbial profiles.
96
Several other oral conditions have been associated
with opioid addiction, namely candidosis, mucosal
dysplasia and bruxism. Oral candidosis has been
frequently observed in such users. Morphine is known
to exert an inhibitory effect on the phagocytosis of
Candida by macrophages, which together with salivary
gland hypofunction, may predispose to oral candidosis
in these people.37
Opioid dependents tend to be high users of tobacco
and alcohol.8 Despite both of these agents being well-
established aetiological factors in leukoplakia and oral
carcinoma and despite studies that demonstrate a
facilitation of tumour growth in mice chronically
exposed to morphine38 there are no data to support a
greater incidence of oral carcinoma specifically in
opioid users.39 However, the concomitant smoking of
cannabis and/or cocaine may be an additional
aetiological factor in the onset of mucosal dysplasia.
These substances contain many carcinogens that are
postulated to render the epithelium more susceptible to
exogenous carcinogens.40,41
Bruxism, which has been reported to be more frequent
in opioid dependents, may be attributed to a general
increase in neurosis in this group of individuals.42 A
similar tendency for bruxism with resultant dental
attrition is also recognized in alcoholics.42,43
Dental management
The dental management of opioid dependents is
often complex. Not only does this group of individuals
suffer high rates of various oral diseases, they also
demonstrate behavioural and pathological changes that
greatly impact upon their dental treatment. As such, the
dental professional needs to be aware of the wider
issues associated with these patients in order to manage
them successfully.
Opioid users often suffer from psychological
problems that are frequently accompanied by general
anxiety. Under the influence of intense pain, any usual
anxiety associated with a psychological disorder may
be dramatically magnified.45 This may explain the
heightened dental fear often exhibited by opioid
dependents.45 Surprisingly, patients taking methadone
may exhibit a phobia for needles, especially in the
hands of others, which further accentuates a heightened
anxiety.45 In such instances, the clinician needs to be
mindful of the importance of managing the patients’
anxiety as well as the primary dental concern. Dental
anxiety may become potentially life threatening should
the patient suffer from chronic hypo-adrenocorticalism,
which may be present due to the metabolism of the
adrenal cortex being altered by the exogenous opioids.
With chronic abuse, an adrenal crisis may ensue
consequent to a diminished adrenocortical reserve
when an opioid user is faced with surgical stress.46
The successful management of pain and anxiety in an
opioid dependent may be difficult to achieve. Opioid
users may demonstrate a reduced responsiveness to
local anaesthetics, most likely due in part to the
Australian Dental Journal 2002;47:2.
pharmacological properties of the opioids used as well
as to general fear and anxiety.47 However, it should be
borne in mind, that drug dependents may present with
a fictitious history of pain and allergy and feign
inadequate analgesia in order to obtain specific classes
of analgesics or sedatives.48 Should pain control not be
achievable with local analgesia, the clinician may resort
to other forms of sedation. Pain control using
intravenous sedation techniques may also prove
unsuccessful due to tolerance and difficult cannulation,
particularly in intravenous drug users.49,50 Even the
administration of a general anaesthetic may not be
desirable on the basis that it is potentially capable of
inducing a relapse in a recovering drug user.51
When treating drug dependents, the dentist needs to
be aware of the fact that these individuals might be
carrying infections that have particular implications for
dental treatment.52 Even though a thorough medical
history may not reveal the presence of such infections,
standard precautions must be observed when treating
opioid addicts due to the high prevalence of such
infectious diseases in this group of patients.
Intravenous drug users are also known to have an
increased incidence of infective endocarditis,52,53 which
has led to a number of centres adopting the principal
that all parenteral drug users should be viewed as
vulnerable to infective endocarditis.53 As such, these
patients may need to be assessed for the need for an
antibiotic prophylactic regime prior to oral surgery or
other dental procedures in which a significant
bacteraemia may arise.54
DISCUSSION
Uncontrolled opioid dependents who present late
with intense pain may place unrealistic demands on the
dental health provider and may not be considered
reliable with regard to regular dental treatment.
Nonetheless, the clinician has an obligation to inform
all patients of their dental health status and offer them
the opportunity to return for comprehensive care.
At the other end of the spectrum, methadone patients
who take a greater interest in their own welfare may
present for comprehensive dental treatment, even in the
absence of dental pain. Despite this, the issues
associated with the management of dental anxiety are
still relevant in this group of patients. A caring and
empathetic approach adopted by the clinician will often
gain the trust of the patient, which in turn should
facilitate more effective pain control and ensure a more
reliable attendance. In addition to restoring the oral
tissues to health, the clinician should emphasize the
importance of prevention from the outset. An
individualized preventive regimen should be formulated
and implemented, considering factors such as regular
hygiene appointments, the use of fluoride and/or casein
products, dietary advice, sialagogues, anti-fungals and
bite splints. With regard to dietary advice, the clinician
needs to take cognisance of the fact that the eradication
of sweet foods from the diet may not be practical in
Australian Dental Journal 2002;47:2.
someone taking an opioid agonist such as methadone.
Rather, an alternative goal may be to accept the
patients’ craving of sweet foods while simultaneously
educating them about the significance of frequency of
sugar intake as well as artificial sweeteners and safe
snacks.
CONCLUSION
The oral manifestations along with the general
medical problems of opioid use are increasingly being
recognized and understood. It is important to develop a
high awareness of the implications for oral health care
in societies where such drug dependency is widespread.
Individuals will be seen at various phases, from states
of neglect and advanced ill health to those undergoing
rehabilitation, including those on methadone
programmes. While the former group generally
presents only in severe pain and may prove to be
unreliable for ongoing care, the latter group, in general,
is responsive to well-structured delivery of oral health
care, incorporating it as an integral component in
attaining a healthy lifestyle.
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Address for correspondence/reprints:
Dr Angelo Titsas
Rapid 68
Letts Gully Road
Alexandra
New Zealand
Email: angelo.titsas@bigpond.com
Australian Dental Journal 2002;47:2.