The FDA stated last week that transmucosal buprenorphine has been associated with dental problems, including tooth loss. The statement was based on 305 reports to the FDA Adverse Event Reporting System (FAERS) database since buprenorphine was approved 20- years ago.
Many of my patients on buprenorphine medications have had dental problems, and the topic was often-described at SuboxForum over the years. It isn’t clear what spurred the FDA to release the warning now. There have been two case series describing tooth damage in patients on buprenorphine but the most-recent report was published almost 10 years ago.
Confounding variables make it difficult to determine whether buprenorphine can harm teeth. Most of the patients who benefit from buprenorphine treatment have histories of addiction, during which they may not have kept up with daily dental care or annual dental visits. Modern preventive dentistry includes flouride treatment and regular x-rays to detect early decay. Early treatment of caries, for example, can prevent severe decay and tooth loss. Use of other drugs, particularly methamphetamine, can cause tooth decay and loss. Opioid use disorder increases acid regurgitation by loosening the gastro-esophageal junction. Reduced frequency of brushing, combined with some dietary factors, also impact dental health.
But the FDA warning states that some people experienced dental problems as soon as two weeks after starting buprenorphine, and that some patients had healthy teeth when buprenorphine was initiated. The average time to diagnosis of tooth decay was about 2 yeasr. Interestingly, the FDA notes that almost 10% of the patients who reported decay were using buprenorphine for pain treatment rather than treatment of opioid use disorder.
The FDA suggests that patients reduce the potential for damage by rinsing their teeth and gums with water after their dose of medication has dissolved, and to brush their teeth an hour later. Many patients hold the dissolved dose of buprenorphine in their mouths for 20 minutes or longer out of concern that they won’t absorb it sufficiently to avoid withdrawal. On average, patients absorb about 30% of an 8 mg dose of Suboxone Film according to the manufacturer. The time required to obtain that degree of absorption is not clear.
The mechanism for dental decay from buprenorphine is not known. Teeth hold up to nighttime grinding and gnashing, acidic and basic foods, and hot or cold liquids. Why would 20 minutes of exposure to buprenorphine cause problems? In a case series, Suzuki suggests that the low pH of buprenorphine/naloxone (3.4) combined with low buffering capacity alters oral flora and increases growth of streptococcus mutans, similar to a process in methamphetamine users. I also remember a letter to the editor of an unknown jounal years ago that questioned possible tooth decay from buprenorphine, suggesting that the opioid effects of the medication negatively influenced immune function in teeth. I don’t know enough about dentistry to say whether that hypothesis is reasonable.
Curiously, most of my 270 patients — many of whom have been on buprenorphine for many years — have had no dental problems. That suggests that rather than a universal effect, damage depends on the presence of multiple factors, such as varied habits or genetic differences between patients. Dry mouth or xerostomia can be caused by medications and health conditions, and has long been associated with dental caries.
In short, the FDA is changing package labelling to add risk of dental decay to orally-dissolving buprenorphine medications. The addition appears to be due to reports of dental decay by some patients and doctors and not the result of a formal study. Hopefully further research will determine whether buprenorphine directly impacts dental health, or if instead it is one part of a contellation of variables.
6 Comments
Anonymous · September 19, 2022 at 2:37 pm
Yes,my teeth got so bad I had to have the top ones removed and dentures by 38. I’ve been in it for 14 years and see no sight of quitting just yet but they sure did a number on my teeth.
J Junig MD PhD · September 19, 2022 at 7:22 pm
So difficult to know. The question is, why do 95% of people NOT have any dental issues while taking it? The FDA released that data, but it was old knews from two articles 8 years ago by private dentists who saw some bad teeth in people taking buprenorphine. They got case reports for their resumes, but there has been no new data since about 2012. The FDA has found no increase in cases in people on buprenorphine. But beyond that, there is no reason proposed for how buprenorphine would damage teeth. Why would 20 minutes of exposure to something in the mouth, with a neutral pH, do damage… when drinking acidic soda all day doesn’t? The teeth spend the whole day grinding and chewing… but 20 minutes of exposure to a non-abrasive, dissolving pill does damage? If it is the opioid effect, why would buprenorphine damage teeth, when years of snorting and injecting opioid agonists don’t harm skin or bone?
Beyond those things, we know that dental injuries take years to appear. Brushing habits now might impact things ten years from now. And so many other variables are involved… flouride treatments as a kid, when adult teeth are developing under the gums… city water vs. well water, since city water usually has flouride added…
And, of course, genetics. As an anethesiologist we often did ‘dental rehab’ on young kids with many cavities, who left the hospital with a dozen silver crowns. They inherited those teeth from their parents.
I’m not saying it is impossible, but to blame buprenorphine someone has to come up with an idea why letting it dissolve in the mouth damages teeth in a small minority of patients, but does nothing to everyone else. Most of my current patients have been with me for 5-10 yrs (I rarely take new patients). Some have dental problems but most don’t. I ask those with dental problems how often they saw a dentist over the past 20 yrs, and most say ‘never.’ I just don’t know.
withheld · December 3, 2022 at 12:37 am
Suboxone totally destroyed my teeth. So much so that due to the amount of decay I had to get all of my top teeth pulled & dentures. Also all of my bottom teeth have decayed to the point where my veneers are constantly coming off. I desperately need to have my bottom teeth pulled & dentures. If I won the power ball the 1st thing I would buy a full set of dental implants.
J Junig MD PhD · December 3, 2022 at 8:14 am
I removed your name for privacy… it is a tough issue and you certainly aren’t alone. The FDA collects data, and now reports that a case report from 2013, by a dentist, suggested seeing more cases of decay in Suboxone patients. But since then, there have been no findings of significant differences in Suboxone patients. A couple problems… first, most people have dental visits twice per year including flouride treatments, and most people brush and floss twice per day. Many people stop going to the dentist regularly during active addiction, and miss out on those treatments. Decay takes years to show up — so lack of flouride in 2010 might just be showing up now in tooth decay. The other problem is that most people taking Suboxone or buprenorphine do not have tooth decay. Out of my 800 patients over the past 15 yrs, I’d estimate that maybe 20% had dental problems, and the rest didn’t. Why? Finally, Suboxone isn’t acidic or caustic, and our teeth generally stand up to repeated sips of soda, chewing on meat, grinding against each other at night…. so what is it that makes Suboxone harmful? Why would 15 minutes of exposure to a neutral substance cause decay?
My point isn’t to challenge you, but to point out the discussions that are held on the topic by docs and health experts. The dentist who wrote the case report suggested that maybe the opioid effect soaks into teeth, and then somehow reduces the immunity against organisms that promote decay… but it is hard to imagine Suboxone saliva soaking through tooth enamel. And then if it DOES reduce the immune system, why doesn’t it lead to an increase in other infections?
I have several patients who have had horrible dental experiences. I also have a couple general psych patients who are not on Suboxone and have bad teeth or dentures. I try to keep an open mind, but I would like to hear some proposed reason WHY Suboxone would harm teeth.
Anonymous · September 24, 2023 at 2:54 pm
When I started suboxone I had a mouthful of teeth. After a few years of taking it, they have just broken off and have had roots removed. It’s horrible. I can’t afford the dental work necessary to have a smile that is complete. In one year I have had 10 teeth or roots removed. I am 62 so people say it’s age but my niece was 41 and she had to have all her teeth removed after starting suboxone. She was unable to deal with not having teeth because she couldn’t afford dentures, and she ended her life. I wish the Pharmaceutical companies would be honest about their products side effects before the Drs. Prescribe them. When you see all the commercials about “ if you took this drug” you realize they’re putting stuff on the market without the screening needed. It’s all about profit and the people suffer while they get richer and richer.They have their minions going to Drs. Offices convincing them to peddle their wares. It should be illegal. They buy the office staff elaborate lunches and gifts to promote their drugs. Never caring about the consequences. The people trust the Dr. So they take the medication and pay the price. What a racket. A Drs. Mistake is what got me in this mess. A botched surgery. Nobody’s held accountable for the harm caused. All the comments I have read and the people I have talked to all have the same factor, the medical professionals started the ball rolling. They created the problem, came up with solution which was faulty, came up with solution to correct problem and created a new one. The patient gets now not only has original problem but now has several added to it. So when they say patient care, don’t believe it. If you didn’t have insurance or cash you’re not getting treatment The Dr gets you hooked on pai meds, then they put you on suboxone and then possibly rehab which is a medical facility so for them it’s a win/ win. They’re making money every step of the way. You end up left hung out to dry. Broke, addicted, in pain and toothless. WOW !! All because of a simple injury, your life is ruined. So while I’m here trying to find a way to get implants at $30,000 per set, unable to smile or chew my food, they’re riding around in their bmw’s tahoes or Lexus’s with beautiful smiles and a pocket full of cash. No repercussions for them only the “patient “.
J Junig MD PhD · September 25, 2023 at 12:33 pm
Sounds like you have a few gripes. I try to call it as I see it, as a patient and as a doc… First, I have never pushed a patient to take pain meds, but I’ve had many, many patients push ME to prescribe pain meds. I suspect it is similar for many docs… they prescribed pain meds because patients demanded them. That whole situation is very complicated, and patients aren’t entirely consistent or innocent when they push for pain meds and then blame the doc for giving in and prescribing them.
As for teeth, those complaints are easy to make… but of the 800 patients I’ve started on Suboxone, why do most of them have good teeth? There is no evidence that Suboxone harms teeth; the FDA recently responded to two case reports from 2013 — both written by the same dentist ‘wondering’ if suboxone can hurt teeth. There is no good proposed mechanism.. why would a soft strip of film with a neutral pH, placed in the mouth, harm teeth — and not acidic soda, chewing on bones and meat, grinding teeth at night, etc? Most of the dental damage that people discover developed over many years… usually years without adequate brushing and flossing, years without fluoride treatments and dental cleanings. There are no legal advertisements related to suboxone and dental caries.
You are mad at the surgeon who didn’t fix you (your back?), mad at the doc who treated your pain — who YOU called for appointments? Then you’re mad at Suboxone for helping you with an addiction, then you blame it for harming your teeth, then you’re blaming the dentists for the cost of implants? AND you’re mad that you need insurance or money to get treatment?
‘Elaborate’ lunches were banned in about 2013, after passage of the ‘sunshine act’. Now, if a rep wants to bring me info on the action of a new medication (a useful service in some cases), they cannot bring food that costs more than the average cost of a work lunch in my area. So yes– I have had reps drop off a couple bagels. Once I got a bowl of soup and a bag of chips from the local deli. But gifts? Seriously? They cannot provide PENS anymore.
Life isn’t fair. Not for anyone. You choose to blame 4 or 5 medical specialties for your problems. You don’t consider that before Suboxone, treatment for opioid use disorder usually didn’t work. My addiction came before Suboxone, so I had to pay over $60,000 for treatment (money I didn’t have at the time). I doubt that type of treatment would have worked for me either without the six years of monitoring and urine drug testing – so I’m grateful for those things.
I don’t know who to blame that my lungs filled up with blood clots last summer, but that wasn’t fair either. But that’s fine — because it doesn’t feel good to blame life’s problems on other people. To do that you have to have a very low opinion of humanity, thinking that all of these people have it in for you, or would hurt you if they could make a dime off your misery. Is that the world you want to live in? Most people don’t — so they accept the fact that even with our best medical efforts, things sometimes go wrong. They would say… YOU hurt your body somehow. That injury is on you. They tried their best to help, and it wasn’t cost-free and it wasn’t perfect… but it is YOUR injury. Back injuries often don’t go well. Spinal fusions have relatively low success rates. But most people still want to proceed with surgery, because THEIR injury is too painful to live with. So the surgeons do what they can.
A final comment — a patient from Canada travelled to see me last month- my second Canadian patient. I will see them if they travel to my office for appointments. This one, like the last, has been waiting for 18 months so far to see a psychiatrist. He talked at length about how hard it is to get ANY type of care in Canada.