Responses to Buprenorphine-associated Oral Diseases: The Critical Need for Mechanistic Understanding

To the Editor: We thank Drs Silva Pedrosa and Aguiar Ribeiro for their thoughtful comments and for highlighting ongoing research efforts addressing the risk of adverse oral health outcomes among individuals treated with buprenorphine for opioid use disorder. The research by Zheng et al1 and others provides valuable insights into the potential biological and microbiological mechanisms underlying our observed epidemiologic associations,2,3 including buprenorphine’s possible effects on salivary composition and biofilm dynamics. As noted in the letter, our study4 was designed to provide population-level, quantitative evidence on the association between buprenorphine treatment and oral health outcomes, complementing prior laboratory-based experimental work. The biological pathways linking buprenorphine exposure to oral disease are likely multifactorial, involving interactions among pharmacologic effects, salivary composition, microbial ecology, and host factors. We agree that further research integrating both mechanistic and population-based approaches will be essential to fully elucidate the pathways by which buprenorphine contributes to oral health complications and to inform strategies for prevention and management among individuals receiving treatment for opioid use disorder. Importantly, the risk of oral health problems should be considered within the broader context of the substantial, well-documented benefits of transmucosal buprenorphine in reducing morbidity and mortality among individuals with opioid use disorder. We again thank Drs Silva Pedrosa and Aguiar Ribeiro for their insightful contribution to this discussion and their commitment to advancing understanding in this important area.