Medical Miracle or Dental Pariah?

New medications, including those for common medical conditions, such as hypertension, diabetes, and cardiac and autoimmune disorders, can significantly impact oral health. In the past decade, many pharmaceutical companies have focused on developing new psychiatric and mental health medications with a particular focus on substance use disorders that frequently accompany mental health issues.

Ever-growing opiate addiction and the need for its treatment elevated the use of substance use treatment medications to entirely new levels. Medications, including buprenorphine and naloxone (brand name Suboxone^®), while used to treat opioid dependence and manage pain, may significantly impact oral health. These effects include adverse changes in the oral cavity, significant interactions with dental procedures, and impacts on post-operative dental pain management. Understanding how newly introduced medications affect oral health is crucial for ensuring patient safety and optimal treatment outcomes.

Suboxone is a crucial tool in fighting the opioid epidemic, helping people regain control over their lives by reducing dependency on opioids while lowering the risk of overdose and misuse. One of the most widely used medications to treat opioid use disorder (OUD), Suboxone is effective in managing opioid dependence while also reducing the risk of misuse compared to other treatments such as methadone.

Suboxone contains two active ingredients: buprenorphine and naloxone. Available in sublingual/buccal film or sublingual tablet formulations, Suboxone films or tablets are placed sublingually or inside the buccal vestibule, allowing the medication to dissolve and be absorbed directly through the mucous membranes.

In sublingual preparations, Suboxone comes in 2.0/0.5 mg, 4.0/1.0/0.5 mg, 8.0/2.0 mg, or 12.0/3.0 mg formulations containing 2.0, 4.0, or 8.0 mg of buprenorphine and 0.5, 1.0, or 3.0 mg of naloxone. The maintenance dose of Suboxone (which usually starts on the third day of treatment and beyond) is available in 4.0/1.0 mg or 8.0/2.0 mg formulations.¹

Other forms of buprenorphine-based medications, such as Subutex (which contains only buprenorphine without naloxone), Zubsolv, and Bunavail, each offer different delivery mechanisms or dosing.² Suboxone remains the most recognized brand today in the treatment of OUDs. The introduction of generic versions has further increased its popularity, driven by lower costs and wider availability.

Indivor Inc, the drug manufacturer, advises patients to take a sip of water, swish it gently around the teeth and gums, and spit out the residue from the Suboxone strip after it has been absorbed by the oral mucosa. Patients are advised to wait at least 1 hour after taking Suboxone before brushing their teeth.¹

Mechanism of Action

Buprenorphine’s mechanism of action is similar to other opioids. A partial agonist at opioid receptors, buprenorphine activates opioid receptors in the brain but to a much lesser extent than full agonists such as heroin, oxycodone, or hydrocodone. Such action helps reduce cravings and withdrawal symptoms without providing the intense high that is associated with full opioid agonists. Additionally, buprenorphine allows patients to gradually reduce their dependence.

Naloxone is an opioid antagonist that blocks opioid receptors and is included in Suboxone to prevent misuse, as Suboxone is an opioid itself.³ The addition of naloxone reduces the potential for abuse, as naloxone discourages attempts to misuse the drug. An alternative version of the medication, Subutex, does not contain any naloxone. Although the most important benefits of Suboxone administration include multiple medical and social factors, the practice shows that the most common beneficial elements include the lower overdose risk and decrease in the intensity of withdrawal symptoms.⁴

Dental-Related Adverse Reactions

Adverse events related to the sublingual/buccal administration of Suboxone sublingual film are oral hypoesthesia, glossodynia, oral mucosal erythema, headache, nausea, vomiting, hyperhidrosis, constipation, signs and symptoms of withdrawal, insomnia, pain, and peripheral edema.⁴

Glossodynia and oral hypoesthesia are the most significant complications. Glossodynia, also known as burning mouth syndrome, causes a burning, tingling, or scalding sensation in the mouth that lasts for at least 4 to 6 months.⁵

Suboxone, like all medications, may cause side effects. While it is generally well-tolerated when used as prescribed, it can still lead to a variety of side effects, especially when misused or taken improperly. Some side effects are serious and may require urgent medical attention, such as respiratory depression, hypotension, liver problems, and adrenal insufficiency.⁶ Although rare, respiratory depression can occur, especially if combined with other central nervous system depressants such as alcohol, benzodiazepines, or other opioids. Therefore, sedation administration in a dental setting needs to be carefully planned.

Liver problems can cause bleeding because the liver can’t produce enough clotting factors, causing coagulopathy. This may make the patient not only prone to hemorrhage but also susceptible to thrombosis due to a parallel reduction in procoagulants and anticoagulant factors.⁷ These possible complications must be considered when planning a surgical dental treatment. Signs of liver failure may include yellowing of the skin or eyes (jaundice), dark urine, severe fatigue, nausea, and upper right abdominal pain.

Adrenal insufficiency is a long-term side effect of opioid use. Buprenorphine can affect the adrenal glands, potentially causing adrenal insufficiency. Symptoms may include fatigue, weakness, dizziness, low blood pressure, and potential shock.

From a dental perspective, chronic long-term side effects of Suboxone use include xerostomia, enamel demineralization, tooth decay, gingivitis, and periodontal diseases. Poor salivary flow caused by opioid effects increases the acidity in the mouth and can significantly contribute to dental erosion.⁸

Suboxone can have serious interactions with other medications or substances used during dental treatment, such as benzodiazepines and other opioids. Combining Suboxone with drugs such as alprazolam (Xanax), diazepam (Valium), or lorazepam (Ativan) increases the risk of respiratory depression. Combining Suboxone with sedatives can dangerously depress the central nervous system, leading to severe drowsiness, respiratory depression, and even death.⁹ Concurrent use of other opioids for post-operative pain management is not only dangerous but counteracts Suboxone’s effects, potentially leading to withdrawal symptoms or overdose.

Suboxone has tremendous effects on dental enamel because of its method of delivery: thin transmucosal strip placed sublingually or intrabuccally.¹⁰ The strip takes approximately 10 minutes to fully dissolve. During this waiting period, the highly acidic ingredients in Suboxone can drastically reduce oral pH, resulting in an acid attack on enamel. Additionally, the medication can diminish salivary flow and increase the oral virulence of Streptococcus mutans, raising the risk for dental caries.¹¹

With repeated use of Suboxone, these effects may dissolve the tooth enamel and disturb the normal chemical balance of the oral cavity. In the absence of appropriate precautions, patients may be at increased risk of oral diseases and pathologies. Oral health professional should be prepared to closely monitor patients taking Suboxone to help protect their oral health.

Interactions With Dental Anesthesia

Though chronic opioid use can change the way individuals perceive pain, often leading to a higher pain threshold, the alteration of administered doses is often needed. While some medications can interact with local anesthetics used in dentistry, Suboxone has no evidence-based interactive properties.¹²

As many dentists have seen, administering local anesthetics and achieving profound local anesthesia may present challenges with opioid users. This can be explained by many factors, including altered pain perception caused by long-term opioid use, psychological factors associated with anxiety and depression, and anxiety-driven expectations of pain.¹³ Due to these factors, dentists may need to use alternative or additional methods for anesthesia and pain management for patients with a history of opioid use. Oral health professionals need to be aware of a patients’ Suboxone use to tailor their pain management strategies accordingly.

Need for Altered Pain Management

Patients taking Suboxone or other opioid-dependence medications, such as methadone, may need particular pain management strategies. As opioids may not be practical, or their use may increase the risk of relapse, dentists must coordinate with the primary prescriber to avoid misunderstandings and possible overdose.¹⁴

Suboxone can affect pain management before, during, and after dental treatments. Patients already taking Suboxone or other opioid medications for ongoing pain management therapies may have a reduced response to standard pain management protocols in dentistry. This can complicate post-operative pain control, requiring alternative strategies, such as nonopioid analgesics (eg, nonsteroidal anti-inflammatory drugs or acetaminophen).

Patients taking Suboxone and psychotropic medications, such as antidepressants, antipsychotics, or benzodiazepines, may have altered responses to sedation during dental procedures. It is crucial to understand what adjustments in the dosages of sedatives or anesthetics may be required.¹⁵

Communication Is Key

Dental providers must review medical history and medications for each new and recare patient. Frequently, dental patients (particularly emergency dental patients) do not see opioid treatment medications like Suboxone or methadone as relevant to dental treatment. Additionally, many patients in recovery do not feel their history of past drug use and current medication treatment should be reported to dental providers, especially in cases of noninvasive dental treatment.

Dentists must review all medications the patient is taking to anticipate any potential interactions or complications. Additionally, opioid or stimulant-focused questionnaires should be utilized to identify or assess these areas of potential problems. In many cases, dentists may need to collaborate with a patient’s physician or other prescriber to adjust medications before or after a procedure, especially if it involves surgery or significant pain management. Such efforts provide additional safety for the patient and treating providers.

A Medical Miracle or Dental Pariah?

Since its introduction, Suboxone has become a game-changing medication for OUD, allowing people to control opioid withdrawal symptoms, manage urges, and regain normal function. Subsequently, patients with OUD are able to focus on rehabilitation, employment, and relationships while managing their opioid dependence. As a result, many medical practitioners view Suboxone not just as a short-term panacea but as a substantial pathway to long-term recovery.¹⁶

A practical, accessible, and relatively safe compared to other treatment options, Suboxone offers both medical and societal benefits. Suboxone has earned a strong reputation for its harm reduction, helping millions of people transition away from full opioid agonists like heroin, oxycodone, and fentanyl, reducing the risk of overdose deaths. It delivers the so-called “ceiling effect,” suppressing withdrawal symptoms and cravings without the intense high of full opioids, subsequently lowering the risk of misuse and overdose.³

By combining buprenorphine (a partial opioid agonist) with naloxone (an opioid antagonist), Suboxone controls misuse of opioid drugs and greatly reduces withdrawal symptoms when prescribed and taken correctly. Additionally, Suboxone is more accessible and less problematic than older opioid treatment medications, such as methadone, because it can be prescribed by medical practitioners in traditional office settings and does not require daily visits to treatment centers.

Despite its accomplishments in addiction treatment, Suboxone can present some significant challenges in dentistry. Common dental-related side effects include xerostomia, oral mucosa irritation, and ulcerations. Suboxone reduces saliva flow, thereby decreasing acid neutralization, which may lead to increased oral acidity. This can create a fertile environment for enamel demineralization, caries development, gingival edema, and subsequent oral infections.⁸

When taken as a sublingual tablet or film, Suboxone can cause mucosal irritation or even intraoral ulcerations. Prolonged exposure to the medication may damage the soft tissues of the buccal mucosa and sublingual areas of the oral cavity.

Perhaps one of the primary challenges Suboxone poses for dentistry is pain management due to the development of opioid resistance. Because buprenorphine has a strong affinity for opioid receptors, it makes it difficult for other opioids used in post-operative pain management to be effective. This makes post-operative pain management challenging, particularly after invasive dental procedures such as extractions or implant surgeries. Further complicating post-operative pain management, adjustment of Suboxone’s dosage may be needed, requiring additional efforts to coordinate care with the prescribing physician.

Balancing the Two Sides

When seen holistically, Suboxone is a life-saving drug that significantly enhances the general well-being and standard of living of those battling opioid addiction. Without it, the negative effects of OUD (overdose, social disintegration, and other health issues) perhaps exceed potential dental complications.

Dentists can manage oral side effects by increasing preventive care, educating patients, and carefully managing dry mouth and pain. Regular dental check-ups, increased hydration, and saliva substitutes or stimulants can also help mitigate dental risks. As new medications are introduced, they can significantly affect oral health, dental procedures, post-operative dental pain management, and the overall healing process. Dentists must remain vigilant about patients’ medication histories to prevent complications, ensure effective treatment, and collaborate with healthcare providers when necessary. Patient communication and comprehensive health assessments are key to managing the impact of new medications on dentistry.

Conclusion

Crucial to the opioid crisis response, Suboxone is essential in assisting individuals to overcome their addictions. With the opioid crisis taking tens of thousands of lives a year in the United States and other countries, Suboxone is a critical tool to help people manage their addiction and prevent overdose deaths. For those battling opioid addiction, Suboxone is unquestionably a medical miracle as it provides a route to recovery that drastically lowers the chance of overdose and enhances long-term results.

Conversely, Suboxone is associated with dental complications that must be addressed appropriately. Its benefits to general and public health and recovery far exceed the risks of oral health complications that can be managed successfully by applying evidence-based dental medicine practices.

References

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From Decisions in Dentistry. September/October 2026;12(2):40-45.