Risks of Dental Problems from Buprenorphine

America is in the midst of an opioid crisis. The Centers for Disease Control and Prevention (CDC) estimated more than 75,000 opioid overdose deaths in the 12-month period ending April 2021.

One of the medications used for treating opioid use disorder (OUD) is buprenorphine. It reduces cravings and withdrawal symptoms in people with an addiction to opiates. Along with counseling and behavioral therapies, buprenorphine treatment is one of the most effective ways to treat opioid addiction. This approach, referred to as medication-assisted treatment (MAT), helps people with opioid use disorder achieve and sustain recovery, ultimately reducing the risk of opioid overdose in the long run.

However, like all medications, buprenorphine can cause side effects. In particular, in January of 2022, the FDA had issued a warning about dental problems associated with buprenorphine use, including dental caries (cavities), loss of teeth, and oral infections. This warning is specifically for buprenorphine oral tablets and transmucosal films dissolved under the tongue or placed on the inside of the cheek.

Please continue reading to learn more about the dental adverse events reported with buprenorphine-containing medicines dissolved in the mouth.

What is buprenorphine? How does buprenorphine treat opioid use disorder?

Buprenorphine is a safe and effective medication used to treat opioid use disorder and pain. The Food and Drug Administration (FDA) approved buprenorphine as a tablet in 2002 and as a buccal film in 2015. Buprenorphine is dosed daily, and over time, some patients are eligible for every-other-day dosing. Buprenorphine can be dispensed in physician offices or prescribed for patients to take at home, significantly increasing access to OUD treatment.

Buprenorphine is a partial opioid agonist, meaning it only partly activates opiate receptors (mu receptors). Regarding its mechanism for addiction treatment, buprenorphine replaces the opioids from the receptors they currently occupy. Then, buprenorphine binds strongly to these opioid receptors so that other opioids (opiate pain medications, heroin) cannot occupy them. By doing so, buprenorphine helps reduce withdrawal symptoms and intense cravings for other opioids.

Many formulations of buprenorphine, for example, Suboxone, contain naloxone. Naloxone helps prevent diversion and misuse of buprenorphine, a synthetic opioid. However, there is not enough data on the effects of naloxone on unborn babies. Therefore, buprenorphine-only versions of the medication are available for opioid pregnant women to decrease the baby's exposure to naloxone.

In what forms is the opioid addiction drug buprenorphine available?

Buprenorphine medication is available as regular oral tablets. The transmucosal formulation is another option that includes sublingual tablets and dissolving film (buccal and sublingual). The buccal administration is the placement of the drug product between your gums and your cheeks, while the sublingual drug product is to be placed under your tongue. In addition to the oral and transmucosal route, buprenorphine transdermal patch (skin patch) and subcutaneous (under the skin) injection are other approved formulations.

According to the FDA drug safety communication, transmucosal buprenorphine-containing medicines can lead to dental issues like tooth decay, cavities, oral infections, and tooth loss. This includes any buprenorphine products that dissolved in the mouth such as sublingual tablets, sublingual films, and buccal films used to treat opioid use disorder and pain.

Do opioids cause teeth to decay?

People addicted to heroin or prescription opioid painkillers often experience tooth decay. Several contributing factors include poor nutrition, tobacco use, irregular eating habits, and poor personal hygiene. In addition to lifestyle factors, heroin and opioid drugs can cause cravings for sweet foods and beverages, leading to tooth decay. Also, opiates reduce saliva production and cause xerostomia (dry mouth), a risk factor for tooth decay and periodontal disease (gum disease). Opiates suppress pain, making it less likely that people will seek treatment for oral health problems. Lastly, people battling drug addiction are less likely to seek regular or timely dental treatment due to cost and probably lack of healthcare access, making dental issues worse.

Can Suboxone cause teeth problems?

Suboxone is a combination product of buprenorphine and naloxone. As mentioned, the FDA warns about dental problems with buprenorphine medicines that dissolve in the mouth, specifically sublingual tablets, sublingual and buccal films.

Besides Suboxone, dental problems can also occur with other buprenorphine medicines marketed under brand names like Bunavail (buccal film), Belbuca (buccal film), Cassipa (sublingual film), Subutex (sublingual tablet), and Zubsolv (sublingual tablet). Generics are also available.

Can you have teeth pulled while on Suboxone?

People taking Suboxone (buprenorphine and naloxone) for treating opioid addiction are at a higher risk of dental problems. If there is a need for any dental procedure, including tooth extraction (teeth pulling), these patients need to work with their dentist and healthcare professionals to develop a plan to treat pain after dental procedures.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has published some recommendations for pain management in such situations:

If possible, the use of non-opioid analgesics such as Tylenol or NSAIDs (ibuprofen) is recommended.
You can continue the current dose of Suboxone and add a short-acting opioid like oxycodone or hydrocodone for additional pain relief.
You can temporarily increase the current dose of Suboxone without an additional opioid.
You can stop Suboxone 24-36 hours before your planned dental procedure and use short-acting opioids for pain control.
You can convert from Suboxone to methadone after the procedure.

The treatment plan for post-procedure pain will depend on the dental problems, the severity of pain, and the anticipated recovery time. For minor dental procedures like having a tooth pulled, it is usually possible to manage the pain by taking acetaminophen or ibuprofen and continuing Suboxone at the current dose.

Seeing a dentist for oral health history and baseline dental evaluation

Buprenorphine is a safe and effective medicine to treat opioid use disorder (OUD) and pain. However, the FDA warns that dental problems can occur with patients taking transmucosal buprenorphine medicines, even in people with no prior history of dental issues.

The benefits of buprenorphine medicines to treat OUD clearly outweigh the risks. But it is important to discuss the potential risks of oral disease with your health care professional before treatment initiation with buprenorphine.

It is worth remembering that the FDA has only identified dental health concerns related to the transmucosal dosage forms which include sublingual and buccal tablets or films that come in contact with the oral mucosa.

Depending on your oral health history, your doctor may refer you to a dentist for a baseline dental evaluation before or soon after prescribing treatment with transmucosal buprenorphine medicine. You should work with your dentist to develop a dental caries preventive plan and schedule regular dental checkups. It’s also important to tell your health care professionals and dentist immediately if you notice any problems with your teeth or gums.

Reducing the risk of dental issues with buprenorphine

To reduce your risk of serious dental problems with buprenorphine medicines, you should take extra steps such as making sure the medicine has completely dissolved, then taking a sip of water and gently swishing it around to rinse your teeth and gums before swallowing. You should also wait at least 1 hour before brushing your teeth after taking a transmucosal buprenorphine product.

Buprenorphine is highly effective in treating pain, opioid addiction and improving the survival rate in opioid use disorder patients. The benefits of buprenorphine medicine in treating pain and OUD outweigh its risks of dental problems. In addition to dental caries risk assessment, some simple precautions and dental hygiene while using transmucosal buprenorphine medicines dissolved in the mouth can greatly reduce the risk of dental problems with buprenorphine.

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