Buprenorphine, a medication used to treat opioid use disorder (OUD) and chronic pain, is often administered as a tablet or film dissolved in the mouth, either under the tongue (sublingual) or against the cheek (buccal). While its benefits are widely accepted, the U.S. Food and Drug Administration (FDA) has issued a warning regarding a direct link between transmucosal forms of buprenorphine and serious dental problems. These issues, which include severe tooth decay, cavities, and tooth loss, have been reported even in patients with no prior history of dental issues. This article explores the mechanisms behind this damage and outlines the necessary steps patients can take for prevention and treatment.
How Sublingual Buprenorphine Causes Tooth Damage
The formulation of buprenorphine designed for dissolving in the mouth is inherently acidic, which is the primary cause of damage. The pH of buprenorphine dissolved in water has been measured at approximately 3.4, comparable to substances like orange juice or vinegar. Tooth enamel, the hard outer layer protecting the tooth, begins to demineralize and soften when the mouth’s pH drops below 5.5.
Holding this acidic formulation in the mouth for several minutes, as required for proper absorption, subjects the teeth to an extended acid bath. This prolonged contact leads to the rapid erosion of enamel by directly exposing the oral cavity to damaging acidic conditions.
Compounding the problem, buprenorphine, like many opioid-based medications, can reduce the production of saliva, a condition known as xerostomia or dry mouth. Saliva is the body’s natural defense mechanism, working to neutralize acids and wash away bacteria and food particles. When saliva flow is reduced, the mouth loses its ability to buffer the low pH created by the medication, leaving the enamel vulnerable to acid attack.
Identifying and Addressing Dental Erosion
The damage caused by the medication often begins as dental erosion, which is the loss of tooth structure due to chemical acid action, rather than traditional bacterial cavities. While secondary cavities can develop later, the initial symptoms often involve increased tooth sensitivity to hot, cold, or sweet stimuli. Patients may also notice that the edges of their teeth appear chipped or that their teeth look smoother and more translucent due to the loss of enamel.
The location of the damage frequently provides a clue, as it is often concentrated on the surfaces where the medication rests, such as the lingual (tongue-facing) surfaces of the lower teeth. Reported dental issues range from pervasive cavities and tooth erosion to dental abscesses and, in some severe cases, total tooth loss. This serious damage has been reported to develop relatively quickly, with a median time to diagnosis of about two years after starting treatment.
Once damage has occurred, professional dental intervention is necessary to restore tooth structure and prevent further decline. Dentists may use high-concentration fluoride treatments to help remineralize and strengthen the remaining enamel. More extensive damage may require restorative procedures such as fillings, bonding to repair lost structure, or the placement of crowns. Open communication between the patient, the prescribing physician, and the dentist is necessary to create a personalized prevention and treatment plan.
Patient Strategies for Protecting Teeth
Patients taking buprenorphine can adopt specific strategies to mitigate the risk of dental damage. A critical step is to rinse the mouth immediately after the medicine has completely dissolved. Patients should take a large sip of water, swish it gently around the teeth and gums to wash away the acid residue, and then swallow. This simple action helps to neutralize the acidic environment created by the dissolving medication.
It is advised to wait at least one hour after taking the dose before brushing the teeth. Brushing immediately after acid exposure can further abrade the softened enamel, causing more damage. Instead, patients should use a soft-bristled toothbrush and fluoride toothpaste, preferably a high-fluoride or prescription-strength option recommended by a dentist, at other times of the day.
To counteract dry mouth, patients should focus on staying consistently hydrated by drinking water throughout the day. Chewing sugar-free gum can help stimulate saliva flow, which restores the mouth’s natural acid-neutralizing capacity. Over-the-counter or prescription saliva substitutes and rinses are also available to help manage persistent dryness. Informing the dentist about the medication is necessary, as they can perform a baseline dental evaluation and establish a personalized prevention plan, including regular checkups.