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.
4 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.