Oral Health Risks of Transmucosal Buprenorphine: Commentary on Tuan et al. and Zheng et al.

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.