Originally posted 10/21/2012
I have received a several emails over the past few years from people who experienced deteriorating dental health while taking buprenorphine or Suboxone.  I also have patients in my practice who have had extensive dental work, and wonder if Suboxone is to blame for their cavities or other problems.
I wrote about this issue several years ago.  At that time I wrote that there was no evidence that sublingual buprenorphine or Suboxone cause or accelerate tooth decay.  After writing the article I received a number of angry emails from people who insisted that I was wrong.
Let’s step back for a moment to highlight the difference between thinking something vs. proving something.  Some people misunderstood my comments about tooth decay and Suboxone, thinking that I was arguing that Suboxone does not harm teeth.  That was not what I wrote.  My point was that as of that time, there was no evidence that Suboxone or buprenorphine caused tooth decay.  When I write about the science of buprenorphine, I try my best to distinguish between what I think is true vs. what was established through scientific study.
I recently met with a patient who has had extensive dental work over the past few years, the same time that she was taking sublingual buprenorphine.  She asked if I thought that the two were related.   I made a few comments (that I’ll be getting to), but also promised her that I would do a literature search, to see whether any connection has since been established.  Ironically, a case report of a woman on Suboxone who required extensive dental work was just published yesterday.  The case report is in the latest issue of The American Journal on Addictions, and the same case is cited in the October 20, 2012 edition of Reactions Weekly.
The world of science is not efficient.  Knowledge moves forward slowly, based on findings amassed from many studies, often repeated multiple times.  Case reports are not intended to prove something.  In fact, case reports are often unusual clinical examples that defy the norm.  They are often published to point out an area that deserves more study.
I cannot copy the case report here because of copyright laws.  But the case described a 35-y-o woman who used oxycodone for about a year at doses up to 160 mg per day, and then went on buprenorphine/naloxone.  After 18 months, her dentist told her that she had extensive decay of 4 molars requiring root canal.  She reportedly had minimal history of dental problems before starting opioids or buprenorphine.
The author of the case report hypothesized that if there is a connection between Suboxone and tooth decay, one reason could be xerostomia, i.e. dry mouth, caused by buprenorphine.  The lack of saliva was my thought, too, as a mediator of any possible effects of buprenorphine on teeth.  Saliva serves an important role in dental health, including rinsing away food particles and acting as a buffer.  The patient in the case report did not report a dry mouth, so the author pointed out that all opioids have some ability to suppress the immune response, and perhaps buprenorphine and/or naloxone reduce the immune response, allowing for greater destruction of teeth by bacteria.
The case report, surprisingly, did not say which buprenorphine product(s) the patient had used, e.g. tablets, film, or generic buprenorphine.
What needs to happen next is for someone to do a case-control study of patients on buprenorphine, to see if they are more or less likely to have tooth decay.  The most valuable study is usually a prospective, randomized clinical trial;  that would not be proper here, since it would not be appropriate to randomize subjects to buprenorphine vs. no buprenorphine.  But a close second would be a case controlled study, where patients on buprenorphine are matched to ‘controls’ with similar characteristics— age, sex, eating habits, income level, education, etc.– and the dental outcomes are followed forward over a number of years.  A less-costly, less-reliable study is one that looks backward, comparing patients on buprenorphine with those not on buprenorphine to see which group has a higher incidence of dental caries.
We are not much better off at this point in our knowledge of whether Suboxone or buprenorphine predispose toward tooth decay.  The case report only mirrors what I see in my practice.  But as I often tell patients, I have other patients who are not on buprenorphine or Suboxone, who have tooth problems.  I also have patients on Suboxone with great teeth.  Hopefully some ambitious PhD candidate will sort through the issue soon.


Matthew · July 6, 2017 at 12:58 am

Hi there doctor not sure if you are still online but yes I have noticed a decay of my teeth that is not normal I believe it is the suboxone. Any tips on what to do?

    Jeffrey Junig MD PhD · July 6, 2017 at 10:01 am

    I’ve heard the complaint before. There are no increased reports of tooth decay on drug reporting sites at the FDA. I’ve spoken to dentists about it- in fact, just yesterday I had that conversation with a dentist– and the suggestion I always hear back is that if a drug dries the mouth, that can cause increased caries, since saliva protects the teeth.
    There was also a case report several years ago where a dentist wondered if the opioid effect of buprenorphine reduced the activity of white blood cells in the inner, living section of teeth, and if that could cause decay. The report was not evidence, but just an idea that the dentist had.
    I think the main thing is to make sure you have a normal amount of saliva, and if not, consider using products that add moisture to the mouth. There are many factors in who gets caries– strong genetic influences, early exposure to fluoride, diet, use of fruit drinks and soda, regular care by a dentist, and of course brushing and flossing…
    It is also not uncommon for people to have few dental problems throughout their lives, then suddenly have tons of cavities.
    Did you ask your dentist about his/her thoughts on buprenorphine?

      Matthew · July 7, 2017 at 9:50 am

      No I have not spoken with him just my pharmacist and she said the same thing.. I just want to thank you from the bottom of my heart for all that you do.. you truly are a great man.

      Matthew · July 7, 2017 at 10:03 am

      Hey doc Iam sorry for posting this topic in this title heading being about teeth but I have a problem .. I relapsed for the past two days.. I have been on subs for five years and I am wondering if after using fentanyl pills for two days will I be okay to dose my subs?

Jeffrey Junig MD PhD · July 18, 2017 at 6:43 am

Um… what? I do have a job, dude. I try to answer questions when I have time. You have some interesting expectations about life.

    Jeffrey Junig MD PhD · July 18, 2017 at 5:06 pm

    Guess so. Just some guy trying to help you out– for free. Dude.
    BTW… I tend to use that word often when someone pushes. Maybe you’ll find a better way to service humanity- I’m fine knowing ‘this is the best I can do.’

Matthew · July 18, 2017 at 11:58 pm

I apologize I haven’t been doing the best lately, you do do a lot for people and I respect that.. please accept my apology as i haven’t been in the clearest of mind states lately

    Jeffrey Junig MD PhD · July 19, 2017 at 6:08 am

    I appreciate that, and I’m sorry for snapping too. I know that most people who stop by are in the middle of difficult issues. As for me, I’m just trying to keep up with things, and sometimes I don’t have a chance to get back here for a week or longer. Be sure to use the forum– suboxforum.com — because there are moderators who are there all the time, many times per day– and each of them have been working with buprenorphine for years.
    Feel free to write back here, and I’ll be happy to answer any questions- or at least give it a shot!

colek1977 · August 18, 2017 at 7:12 pm

I am a 40 yo healthy male. I have been taking Suboxone for about 9 years. Up until about 4 years ago I had never had a cavity in my life. Now I am dealing with Cavities in all 4 back teeth and a small cavity in one of my front bottom eye teeth. I have also been theorizing about Suboxone, possibly being the culprit.
I have taken meticulous care of my teeth for my entire life. Now its like I have Meth Mouth of the Back Teeth. 2 of my back teeth have completely sheared off into sharp angles.
I have had one extracted, but at this time I have no way to pay for the extensive repair that has overcome my teeth.
For me my whole life my healthy nice teeth were a source of pride in a sense. Most all my family members had lost their teeth early in life, due to bad and inadequate care of their teeth.
Personally I am at a loss and do not know where to turn.
I am not 100% convinced that tooth loss is only caused by dry mouth, personally I feel that there is a closer correlation with the way the meds are administered, under the tongue, right next to the back teeth. Sucralose Should be looked at closer. Just my personal thoughts.
Thanks for the article,
I just pray that I can find relief without having to turn back to the opiates and another stint of possible addiction.

Anonymous · September 22, 2022 at 9:41 am

I’ve had almost all my tips pulled. Feel for ya.

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