Suboxone and dental decay: what does the evidence show?

Abstract

OBJECTIVES: The US Food and Drug Administration (FDA) issued a warning about buprenorphine-induced dental caries of unknown mechanism in 2022. To investigate the potential mechanism, the association between local buprenorphine exposure and dental biofilm formation will be explored in this study. METHODS: Female F344 rats were dosed with sublingual buprenorphine film or intravenous injection to explore the oral cavity exposure of the buprenorphine. The buprenorphine distribution in salivary glands after the sublingual and intravenous administration was also evaluated. To investigate the effects of buprenorphine exposure on dental caries formation, buprenorphine's impact on the biofilm formation of S. mutans in vitro was measured. RESULTS: The absolute sublingual bioavailability of buprenorphine in rats was 17.8% with a high ratio of oral fluid exposure to blood concentration in the pharmacokinetic study. Salivary gland concentrations of buprenorphine and its active metabolite norbuprenorphine were significantly higher than their blood concentrations after both sublingual (s.l.) and intravenous (i.v.) administration. Correlation analysis showed that the oral fluid concentration of buprenorphine and norbuprenorphine was highly correlated to salivary gland concentration rather than blood concentration. These data indicate that the salivary gland serves as an accumulation organ for buprenorphine, allowing prolonged oral fluid exposure to buprenorphine. Lastly, buprenorphine and its metabolites contributed to the biofilm formation of S. mutans in high concentration. CONCLUSIONS: Sublingual administration substantially increased the salivary gland distribution of buprenorphine and norbuprenorphine. Depot effects following sublingual dosing and salivary gland accumulation likely sustained high oral fluid exposure to buprenorphine and stimulated the biofilm formation of S. mutans.

Abstract

The labeling for transmucosal buprenorphine products will now include a warning that the drug may cause serious dental problems such as tooth decay, cavities, oral infections, and tooth loss.Nurses and NPs should complete an oral history and assessment prior to patients beginning treatment. Patients should be informed of these potential adverse effects and encouraged to receive regular dental care.

Abstract

Opioid use disorder affects millions of people nationally and in 2022 opioid overdose deaths exceeded 80,000. Buprenorphine, a partial mu-opioid receptor agonist, is a gold standard treatment for opioid use disorder, improving withdrawal symptoms and decreasing opioid-related mortality. However, a 2022 Food and Drug Administration warning about oral health problems related to transmucosal formulations has precipitated new research into this medication's potential risks. Two timely studies included in this issue of Journal of Addiction Medicine provide important new insight into potential causal effects and mechanisms of transmucosal buprenorphine's impact on oral disease. Using propensity score-weighted survival analysis, Tuan and colleagues demonstrated significantly greater risk for oral health problems in patients with opioid use disorder exposed to transmucosal buprenorphine compared to those not exposed. Taking a vastly different approach, Zheng and colleagues explored mechanisms of oral health risk by exposing rats to transmucosal or intravenous buprenorphine. Results described prolonged oral fluid buprenorphine exposure, a condition proposed to increase risk for tooth decay, was associated with greater accumulated buprenorphine in the salivary gland associated with sublingual buprenorphine administration. These novel studies advance our understanding of the plausibility of a causal relationship between transmucosal buprenorphine and oral health problems and suggest the importance of prescriber-patient discussions about risk mitigating oral hygiene practices and close monitoring of oral disease development. Additional research is needed into the relative oral health risks of full-opioid agonist versus transmucosal buprenorphine exposure and current barriers to long-acting injectable buprenorphine.

Abstract

PURPOSE: To study the oral health and dental neglect of prenatally buprenorphine-exposed 3-year-old children. METHODS: The study consisted of 51 children who as newborns tested positive for buprenorphine in a urine screen. The control group comprised 68 children previously unexposed to narcotics. The dentist examined the children and interviewed their guardians. RESULTS: Buprenorphine-exposed children exhibited significantly more early childhood caries than did the control group. Caries indices, the number of decayed, missing and filled teeth or tooth surfaces and decayed teeth were greater in the buprenorphine-exposed children than the control children (p = 0.004, p = 0.004, p = 0.001, respectively). In the buprenorphine group, more children showed visible plaque (p = 0.003) and fewer children were caries-free (p = 0.009) than in the control group. The control children's teeth were also brushed more often than the buprenorphine-exposed children's teeth (p = 0.001) and the parents were more involved in their children's tooth brushing than were those in the buprenorphine-exposed group (p = 0.035). CONCLUSIONS: More caries and dental neglect were found in buprenorphine-exposed children than in controls. These findings highlight the importance of routine dental appointments, caries screening and preventive care for children in substance-abusing families.