Cannabis: Oral Health Effects

Cannabis is a genus of annual flowering plants found in temperate zones around the world, with a long history of use for industrial, recreational and medicinal purposes.¹ The plant Cannabis sativa acts as a mild sedative and mood enhancer for recreational users and is used for its analgesic and antiemetic properties in clinical applications.^2-4 The dried leaves of the cannabis plant can be smoked as marijuana, which is its most common form, currently used by 12% of American adults,⁵ up from 7% in 2013.⁶ The proportion of users has increased dramatically since the early 1970s; in a 2017 survey, about 45% of Americans said they had at least tried marijuana.⁷ Starting in 2012, certain U.S. states began legalizing the substance for medical and/or recreational usage.^{6, 8, 9} Notwithstanding the gain in the social and legal acceptance of cannabis, public health concerns remain.

Chemical analysis of cannabis finds more than 500 compounds, of which over 120 are cannabinoids, a class of chemicals that directly interact with the nervous system’s endogenous cannabinoid receptors.^{4, 10, 11} From a neurotropic perspective, tetrahydrocannabinol (THC) is the most important of these cannabinoids, responsible for its psychoactive effects. The concentration of THC determines a cannabis product’s potency and varies widely across and within various preparations;^{2-4, 10, 12} THC potency of cannabis products has been observed to be increasing over time.^13-15

The dried leaves and flowers of the cannabis plant are usually rolled into cigarettes (“joints”^{10, 15}) or placed in a water (“bong”¹⁵) or other pipe and smoked, or its resin or oil forms (hashish and hash oil, respectively) is ingested or inhaled. When smoked, marijuana delivers average THC concentrations between 0.5% and 9.6%.^{2, 12}

Cannabis can also be vaporized through a non-combustive heating process that releases psychoactive compounds such as THC, which are inhaled by the user. Several vaporizer models, including pen-sized and tabletop devices, are used for vaping cannabis herb, wax, or e-liquid.¹⁶ Initial research has shown that cannabis vaping has become increasingly popular among adolescents,¹⁷ and can also produce stronger subjective drug effects and impairment in cognitive functioning.¹⁸

Another method of cannabis administration, known as “dabbing,” uses concentrated butane hash oil, which is vaporized rapidly and inhaled.¹⁹ Dabbing with cannabis concentrate is a highly potent mode of administration, with THC concentrations ranging from 66.4% to 75.5%.^{10, 20} The practice of dabbing has been cited as a causal factor in a case report of acute lung injury mimicking pneumonia,²¹ as well as adverse events associated with the high THC concentration (e.g., incapacitation, vomiting).²²

Cannabis can also be mixed into food substances, and numerous cannabis-derived food products are available for medicinal or recreational purposes, particularly in U.S. states that have legalized recreational marijuana.²³ Some food products contain forms of hashish with THC concentrations ranging from 2% to 20%.^{2, 10, 12} Consuming foods containing cannabis or cannabis-derived compounds (e.g., THC) is associated with slower onset of psychoactive effects, which can be delayed by one to three hours.¹⁰

The neurological and behavioral effects of cannabis include a sense of well-being coupled with immediate cognitive and psychomotor impairment.^{3, 4, 14, 18, 24} Frequent use has long been associated with chronic systemic health effects, including addiction^{14, 15, 25} and disruption of brain development,^{4, 25} particularly among adolescents—who are not only the most likely to try the drug but are also at a critical period for brain development.^{4, 14, 25, 26} Cannabis use in adolescence is also associated with an unclear relationship with psychotic disorders and an exacerbation of psychotic symptoms, including schizophrenic episodes.^{8, 14, 25-28}

Immediate cardiovascular effects of cannabis include increased heart rate (tachycardia) and microcirculation disruptions that can lead to a number of serious conditions, from myocardial infarction to stroke, and vascular occlusive diseases referred to as “cannabis arteritis.”^{4, 10, 15, 25, 29-32} In addition, there are case reports of sudden cardiac death during intoxication,^{4, 25, 30} plus one study that found greater risk of increased systolic blood pressure after cannabis use.³³

Cannabis contains many of the same carcinogens as tobacco, and chronic smoking of marijuana is associated with similar respiratory pathologies as tobacco smoking,^{2-4, 14, 24, 30, 34-36} although co-occurrence of tobacco and marijuana smoking complicates ascribing causality to cannabis.

The evidence base for cannabis use as a therapeutic medication is in its infancy.^1,37 There is some evidence supporting cannabis as an antiemetic and as an appetite stimulator for patients with cancer and AIDS, as well as a pain and spasm reducer for a number of chronic conditions.^{14, 37-41} Some studies have suggested that cannabis has anti-inflammatory or antibacterial properties,^{4, 42} as well as having utility as a therapy for glaucoma because of its effects in reducing intraocular pressure.^{4, 25, 40} Medicinal cannabis can be administered in botanical (i.e., smoked) form, added as an ingredient in food, inhaled as a vapor/mist, applied topically, or ingested as a pharmaceutically manufactured medication.^{14, 43} Examples of pharmaceutically manufactured cannabis-related/cannabis-derived drugs approved by the FDA include:⁴⁴

• Dronabinol, a synthetic form of THC commercially marketed as Marinol^® (capsule) and Syndros^® (oral solution)
• Nabilone, a synthetic drug with a chemical structure similar to THC commercially marketed as Cesamet^®
• Epidiolex^®, a purified form of cannabidiol (CBD), a non-psychotropic cannabinoid; derived from cannabis

Pharmaceutical administration in tablet or capsule form is more common among individuals who are not accustomed to smoking recreationally,⁴³ and most studies do not show a significant difference in effectiveness among modes of administration.^{1, 43}

CBD is one of several cannabinoids found in the cannabis plant. Unlike THC, it is non-psychotropic and has been increasing in popularity for its claimed use of providing relief from conditions such as anxiety, depression, insomnia, pain, and epilepsy.⁴⁵ Popular CBD forms include CBD suspended in oil, alcohol (tinctures), or a spray administered sublingually, vaporization liquid, capsules/pills, topical creams, and edibles.^{46, 47} Although hemp (cannabis with a THC concentration of ≤3%) is no longer considered a controlled substance under the Agricultural Improvement Act of 2018, over-the-counter CBD products and dietary supplements containing or derived from cannabis are not FDA-approved.

More studies of cannabis-derived compounds in clinical trial settings are needed to assess safety and efficacy. The FDA has not approved a marketing application for CBD products for the treatment of any disease or condition with the exception of the prescription drug Epidiolex^® (mentioned above), which contains a purified form of CBD and is used to treat seizures associated with two rare and severe forms of epilepsy (Lennox-Gastaut syndrome and Dravet syndrome).⁴⁴

The use of cannabis, particularly marijuana smoking, has been associated with poor quality of oral health,^{2, 3, 10, 15, 48} but etiology has been complicated by the number of associated factors with frequent users, including: concomitant use of tobacco, alcohol, and other drugs; poor oral hygiene practices; and infrequent visits to dentists.^{2, 3, 10, 24, 49} It also leads to xerostomia (dry mouth), which can contribute to a number of oral health conditions.^{2, 4, 10, 15} Further, the main psychotropic agent, THC, is an appetite stimulant, which often leads users to consume cariogenic snack foods.^{10, 50} Regular cannabis users are known to have significantly higher numbers of caries than nonusers,^{2, 10, 29} particularly on normally easy-to-reach smooth surfaces.^{10, 51}

Leukoedema is more common among cannabis users than non-users but it is unclear whether associated irritants, such as orally inhaled smoke, rather than cannabis itself, may be contributing causes.^{10, 48} Smoking marijuana is associated with gingival enlargement,^{2-4, 10, 29} erythroplakia and chronic inflammation of the oral mucosa with hyperkeratosis and leukoplakia,^{2-4, 10} sometimes referred to as “cannabis stomatitis,” which can develop into malignant neoplasias.^{2, 4} It has been reported that a synergistic effect between tobacco and cannabis smoke may increase oral and neck cancer risk for people who smoke both.^{2, 36} The risk and aggressiveness of cancers associated with cannabis appear to be higher in younger (i.e., <50 years old) users.^{2, 48} Immunosuppressive effects of cannabis, especially in association with oral papillomavirus in smokers,^{2, 52} may contribute to these increased risks of cancer,^{2, 53} but other studies have found no association between marijuana use itself and head and neck cancers.^{8, 54, 55}

The immunosuppressive effects of cannabis may contribute as well to a higher prevalence of oral candidiasis compared to non-users.^{2, 3, 10, 25, 48} It has been hypothesized that hydrocarbons present in cannabis provide an energy source for Candida albicans, resulting in increased presence and density of colonies.^{2, 48} Alternatively, the generally poor oral hygiene among many cannabis smokers may promote candidiasis colonization.^{2, 3, 10, 48} Recent research has suggested that viable microbiota may be transmitted from contaminated marijuana, which could further exacerbate a pathogenic oral environment.⁵⁶

A number of studies have suggested a direct relationship between cannabis use and periodontal disease,^{2-4, 10, 12, 57} including a 2019 systematic review⁵⁸ and a 2020 rapid evidence review.⁵⁹ Recent studies have tested the relationship between periodontitis and frequent cannabis use and adjusted for confounding factors such as cigarette smoking, alcohol use, social status and other health issues.^{12, 58, 60} Significantly higher rates of periodontitis were observed among the frequent users compared to non-users, with significantly higher numbers of sites with high pocket depths (≥4 mm) and attachment loss.^{12, 60} Further, periodontitis may occur at an earlier age in marijuana users than the general population with chronic periodontitis.^{12, 57, 61-64} A study of adolescents in Chile, however, found no association between regular use of cannabis and periodontal disease,⁶⁵ but it may be expected that long-term use would result in periodontal disease later in life.⁶² In a histometric experiment, laboratory rats exposed to marijuana smoke had a significant increase in alveolar bone loss due to periodontitis,³⁵ despite research that has indicated that specific cannabinoids, such as the non-psychotropic cannabidiol (CBD), may prevent bone loss.^{66, 67}

Signs and symptoms of an active (intoxicated) cannabis user include:^{15, 29}

• Euphoria
• Hyperactivity
• Tachycardia
• Paranoia
• Delusions
• Hallucinations

A currently intoxicated (i.e., “high”) user may present several difficulties for the dental practitioner. Increased anxiety, paranoia and hyperactivity may heighten the stress experience of a dental visit.^{2, 4, 15, 24, 29}  Increased heart rate and other cardiorespiratory effects of cannabis make the use of epinephrine in local anesthetics (for procedural pain control) potentially life-threatening.^{4, 29, 59} Patients may be unwilling to self-report marijuana use or unable to answer reliably, but determination of intoxication may be possible during the routine cardiac risk assessment.¹⁵ It is because of the dangers of administering epinephrine or products containing alcohol to a “high” patient,^{3, 4, 24, 29, 30} in addition to increased anxiety and paranoia, that dentists may refuse to treat the intoxicated patient,⁶⁸ or consider postponing non-emergency treatment for at least 24 hours.²⁹  Additionally, there may be legal implications regarding validity of informed consent with intoxicated patients, especially with irreversible procedures like extractions. Effects of acute intoxication effects are reported to subside within 2 to 3 hours.^{10, 15, 29}

The following dental findings may indicate a chronic recreational cannabis user:^{2-4, 10, 29, 69, 70}

• Xerostomia
• Leukoplakia
• Periodontitis
• Gingival enlargement/hyperplasia
• Increased decayed, missing or filled teeth
• Stomatitis
• Candidiasis
• Alveolar bone loss

If the patient appears to be a user, it may be helpful to understand whether the use is medicinal, as this may suggest relevant comorbidities.¹⁵ Verification of cannabis use may be an opportunity to discuss other health consequences and inform the patient of the importance of fluoride, good oral hygiene practices, and healthy snacking.⁷¹ 

When dental health care providers suspect cannabis use, it is recommended to:^{4, 10, 29}

• Complete a comprehensive oral examination and include questions about cannabis use in a thorough dental and medical history.
• Emphasize the importance of regular dental visits and oral care.
• Encourage healthy, nutritious snacks over sweet, cariogenic snacks.
• Consider employing preventive measures, such as topical fluorides.
• Consider treatment for xerostomia, while avoiding alcohol-containing products.
• Keep advised of current changes in applicable laws on recreational or medicinal cannabis.

Statement on Provision of Dental Treatment for Patients with Substance Use Disorders (Trans.2005:329)

1. Dentists are urged to be aware of each patient’s substance use history, and to take this into consideration when planning treatment and prescribing medications.
2. Dentists are encouraged to be knowledgeable about substance use disorders—both active and in remission—in order to safely prescribe controlled substances and other medications to patients with these disorders.
3. Dentists should draw upon their professional judgment in advising patients who are heavy drinkers to cut back, or the users of illegal drugs to stop.
4. Dentists may want to be familiar with their community’s treatment resources for patients with substance use disorders and be able to make referrals when indicated.
5. Dentists are encouraged to seek consultation with the patient’s physician, when the patient has a history of alcoholism or other substance use disorder.
6. Dentists are urged to be current in their knowledge of pharmacology, including content related to drugs of abuse; recognition of contraindications to the delivery of epinephrine-containing local anesthetics; safe prescribing practices for patients with substance use disorders—both active and in remission—and management of patient emergencies that may result from unforeseen drug interactions.
7. Dentists are obliged to protect patient confidentiality of substances abuse treatment information, in accordance with applicable state and federal law.
   
    

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Professional Resources

• ADA Oral Health Topics page on Xerostomia
• ADA Catalog: The ADA Guide to Substance Abuse Disorders and Safe Prescribing (Item #P035)
• Search JADA for articles related to cannabis
• ADA Library Services

 

Patient Resources
ADA MouthHealthy Nutrition: What You Eat Affects Your Teeth.

American Society of Addiction Medicine

FDA: What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD

Mayo Clinic: Drug Addiction, Marijuana and Depression

National Institute on Drug Abuse (NIDA):

• Drugs of Abuse (click on “Marijuana”)
• Marijuana