Remember the days of everyone from hippie protesters to Sean Paul calling for the government to just "legalize it, already"? Well, the days of legalized marijuana are here—and so are the days of cannabis derivatives. According to Governing magazine, 30 states where medicinal and/or recreational marijuana is legal have also legalized the selling and use of cannabidiol (CBD) oil. (1) As dental hygienists and oral health professionals, what should we make of this? Does it mean anything for our patient's oral health and their dental treatment?
The answer is yes. According to a 2018 article from the American Dental Association (ADA), there are definite considerations for dental professionals: “[C]annabis smoking is associated with periodontal complications, xerostomia, and leukoplakia as well as increased risk of mouth and neck cancers.” (2)
In this article, we'll look at the issue a little closer. Specifically, we'll look at CBD oil, whose use is on the rise.
CBD oil: What is it?
Cannabis is well-known for being smoked as marijuana, but it is now being used frequently in edible and topical products. (2) There are two main molecules in marijuana. The first, tetrahydrocannabinol (THC), is best known as the chemical component that causes altered psychological effects (the "high"). The second molecule, cannabidiol (CBD), can be extracted from the flower and bud parts of the marijuana plant. The key differentiator? CBD can be used without any psychological effects to the brain.
CBD use for severe epileptic disorders is the only condition that has survived tedious scrutiny and research from the greater body of medicine. Ongoing trials and research are still needed to substantiate other claims (e.g., use for anxiety, inflammation, and insomnia).
CBD can be ingested in multiple ways, including inhalation. It can also be formulated as an oil that contains only CBD as the active ingredient (no added THC). It can also be supplied in capsules, dried, or placed into a prescription liquid solution. (3)
Oral health implications
The use of marijuana and its isolated components has been shown to have oral health implications. These include xerostomia, periodontal disease, and increased risk of oral malignancies.
The ADA has noted that "[l]eukoedema 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."(2) Other tissue changes in the mouth may include gingival enlargement, erythroplakia, and chronic inflammation of oral mucosa with hyperkeratosis and leukoplakia. (4–6)
The ADA has also noted that "[t]he immunosuppressive effects of cannabis may contribute to a higher prevalence of oral candidiasis compared to non-users."(1) Furthermore, "it has also been hypothesized that hydrocarbons present in cannabis provide an energy source for Candida albicans, resulting in increased presence and density of colonies." (1)
Other research has concluded that "[c]annabis abusers generally have poorer oral health than non-users, with an increased risk of dental caries and periodontal diseases. Cannabis smoke acts as a carcinogen and is associated with dysplastic changes and pre-malignant lesions within the oral mucosa."(4) A heightened caries risk is largely attributed to increase in xerostomia, while "dysplastic changes in the epithelium of the buccal mucosa were appearing as the result of the action of chemical factors of marijuana smoke." (5)
It als has been suggested that "cannabis smoking may be a risk factor for periodontal disease that is independent of the use of tobacco." (5)Furthermore, "periodontitis may occur at an earlier age in marijuana users than the general population with chronic periodontitis." (2)
Currently, there is conflicting research regarding cannabis’ effects on alveolar bone. In one research study, it was postulated that "CBD may be useful to control bone resorption during progression of experimental periodontitis in rats." (6) Moreover, the paper stated that "gingival tissues from the CBD-treated group showed decreased neutrophil migration (MPO assay) associated with lower interleukin (IL)-1beta and tumor necrosis factor (TNF)-alpha production." (6)The cytokines, or cell-mediators, of IL-1beta and TNF have been demonstrated to be key factors in systemic and oral inflammation. Conversely, a study published in the Journal of Periodontology suggests that in rat models, "[c]annabis sativa (marijuana) can interfere with bone physiopathology because of its effect on osteoblast and osteoclast activity." (7)
Dental treatment implications
It’s important to recognize the signs of an intoxicated patient (legally or illegally) prior to treatment, especially when anesthetic is planned. These signs and symptoms may include the following: euphoria, hygeractivity, tachycardia, paranoia, delusions, and hallucinations. (2)
Other research has noted that "[d]ental treatment on patients intoxicated on cannabis can result in the patient experiencing acute anxiety, dysphoria and psychotic-like paranoiac thoughts. The use of local anesthetic containing epinephrine may seriously prolong tachycardia already induced by an acute dose of cannabis."(4) When suspected, the use of a plain anesthetic is preferred for dental treatment. Lower immunity may compromise healing response following extractions, placement of implants, and surgical and nonsurgical periodontal intervention.
References
1. State Marijuana Laws in 2018 Map. Governing website. http://www.governing.com/gov-data/safety-justice/state-marijuana-laws-map-medical-recreational.html.
2. Cannabis: Oral Health Effects. American Dental Association website. https://www.ada.org/en/member-center/oral-health-topics/cannabis. Published January 22, 2018.
3. Cannabidiol. Wikipedia website. https://en.wikipedia.org/wiki/Cannabidiol. Accessed February 6, 2019.
4. Cho CM, Hirsch R, Johnstone S. General and oral health implications of cannabis use. Aust Dent J. 2005;50(2):70-74.
5. Rawal SY, Tatakis DN, Tipton D. Periodontal and oral manifestations of marijuana use. Journal of the Tennessee Dental Association.2012;92(2):26.
6. Napimoga MH, et. al. Cannabidiol decreases bone resorption by inhibiting RANK/RANKL expression and pro-inflammatory cytokines during experimental periodontitis in rats. Int Immunopharmacol. 2009;9(2):216-222.
7. Nogueira-Filho GR, Todescan S, Shah A, Rosa BT, Tunes Uda R, Cesar Neto JB. Impact of cannabis sativa (marijuana) smoke on alveolar bone loss: a histometric study in rats. J Periodontol. 2011;(11):1602-1607.
