The recent years have brought a lot of changes for the U.S, including the rise and legalization of medical marijuana. A few states have even legalized for recreational use, which means that health-care providers are increasingly confronted with marijuana users in the clinical environment as patients. Because of legalization, studies on the effects of marijuana concerning health and lifestyle are able to be conducted safely and in controlled environments, which provides beneficial information on the impact it can have on our lives and our health.
The American Medical Student Association discovered that marijuana users tend to get sick more often than non-users, and this may actually have more to do with whether or not the marijuana being used was grown with pesticides and chemicals, as THC is known to be very a beneficial compound with many positive medical benefits. Doctors are also needing to familiarize themselves with the long-term effects of cannabis use and are finding new ways to discuss these habits with their patients.
Marijuana Use and Its Impact On Oral Health
How does medical marijuana affect your oral health? According to several studies, chronic marijuana use can lead to higher incidences of cavities, gum disease, oral cancer, periodontal disease, and gingivitis. Most common are the well-known âcotton mouthâ, a higher risk of cavities, and gum irritation. Marijuana users tend to have poorer oral health than non-users. With higher plaque and decayed/filled/missing teeth scores, there also remains a higher chance of developing oral cancer, oral candidiasis, and other oral infections.
Medicinal Marijuana is often recommended to patients for pain management, insomnia, and a variety of other ailments as a natural alternative to painkillers and pharmaceuticals, whose list of side effects can often be long and dramatic. THC and the other active compounds present in cannabis, such as CBD and terpenes, can produce highly effective and even vastly beneficial results for those fighting cancer and chronic pain, among others. A few patients will even confess to using cannabis to combat anxiety, including anxiety about their dentistâs appointment, and there are even studies underway examining the benefits of medical cannabis to help those suffering from PTSD.
However, health care practitioners remain concerned about the negative impacts when it comes to smoking cannabis, versus ingesting in the form of an edible. By limiting cannabis smoking/use and practicing good oral hygiene, however, it is possible to limit exposure to the harmful impacts smoke and inhalants can have on oral health.
Here are a few of the ways cannabis smoke negatively affects your mouth and teeth, and how you can limit the impact.
Xerostomia
In many cases, users report âcotton mouthâ, also known as xerostomia – caused by under-functioning salivary glands. THC, the psychoactive compound in cannabis, achieves this by binding to endocannabinoid receptors in our brain and sending signals to limit our saliva production for the time-being. Our bodyâs saliva is hugely important – more so than we generally realize because even a slight lack of normal saliva levels can lead to more cavities and higher chances of mouth infections.
In addition to preventing bad breath (halitosis), saliva plays an important role in the protection of our teeth. Itâs another way the body naturally prevents cavities by slowing down tooth decay and fighting infections, like thrush and candida. Saliva also plays an important role in even our speech capabilities, as well as helping us break down food when we eat and preventing high levels of plaque build-up.
Cannabis smoke also has an effect on the bodyâs âappetiteâ hormone, leptin, which regulates appetite and is responsible for why users report the âmunchiesâ. Often, cannabis smokers reach for junk food to satiate the increased hunger, and in combination with lowered saliva production and a decrease in saliva pH, higher intake of sugary and processed foods also leads to higher risk for cavities if oral hygiene is poor.
By taking precautions, cotton mouth from cannabis use doesnât have to mean higher risks for negative health impacts. Doctors can remind their patients who smoke to stay well-hydrated – by drinking WATER. Â Some studies have shown that on average, people reach for carbonated soft drinks or drinks high in sugar to relieve dry mouth instead of water, and this can also lead to more tooth decay. By having an open dialogue with their patients, and reminding them to reach for the H2O instead of soda, doctors can help with awareness and prevention.
Oral Edema/Erythema
Smoke of any sort, whether tobacco or marijuana, carries carcinogens that affect every aspect of the body, and especially affects teeth and gum health. The high temperature involved with burning a plant-based inhalant irritates oral tissues and in some cases can lead to cellular disruption. While marijuana use in conjunction with oral cancer is unclear and research is very limited, studies are underway to determine if it is as harmful as tobacco. At the very least, frequent use can cause irritation of oral tissues, edema, and a host of other issues.
Edema is the medical term for swelling, which means that small blood vessels leak fluid into surrounding tissues and these tissues become swollen. It is generally caused by injury and inflammation, but even a slight irritant such as cannabis smoke can trigger the bodyâs reaction and lead to swollen and inflamed gums.
Smoking cannabis also increases risks for loss of teeth and gum disease and can lead to stained or yellowed teeth. Signs of oral edema include pain and tenderness on the floor of your mouth (under the tongue), pronounced drooling, and even difficulty swallowing. In addition, cankers or small mouth sores and tender, painful, or bleeding gums can occur. The gum tissue can also start to separate from the teeth, creating small pockets where plaque and bacteria like to hide and can cause irritation and even decay.
Brushing daily with fluoride toothpaste and remembering to floss is important. Also, make sure to have regular screenings with your dentist to determine your risk factors and what else you can be doing to help prevent negative oral health.
Ask The Experts – Dental Professionals Weigh in on Oral Health and Marijuana Use
Weâve asked a few dental experts to share their recommendations on habitual/medical cannabis use and how to still maintain good oral health.
Suzanne Hubbard, RDH
Q: If patients admit to smoking marijuana, do you have suggestions or tips on what they can do to mitigate the effects of smoking it?
A: If a patient admits to smoking marijuana and does not wish to quit smoking, I tell my patients to take a teaspoon of baking soda with 8 oz of warm water and swish for one minute after ingesting or smoking marijuana. I advise them to wait for about 30 minutes to brush. What I find with marijuana is that it can leave a sticky film on the teeth, so the baking soda neutralizes the film, and also helps with slight brown/green staining. Then a follow-up brush helps remove the residual film.
Q: Do you ask patients if they smoke marijuana on your intake forms?Â
A: I am very open and honest with my patients about any and all substance use, from marijuana to meth. So many people do not know the relationship of oral health and substance use. Our intake forms include all forms of substance use right alongside the medical questions. We have a section in the medical form that introduces the question of smoking, then proceeds into marijuana and other substances.
Q: Do you have any suggestions or tips on how to verbally ask patients if they smoke marijuana for those that didnât disclose it in the forms. Also, do you have any idea how many people donât disclose on forms versus what you are told in person?
A: When taking radiographs on patients, I get to know my patients, asking what they do, how long they have lived in the area etc. Â When talking with the patient at this time, risk factors are then brought up. “So how many times a day do you brush? âAre you a flosser?â âHey, I am noticing on your x-rays some areas of decayâ âDo you happen to drink soda pop?â âHave you ever been a drug user?â Â âHow about Meth?â âWe live in Colorado, and you know marijuana…are you a user at this time?â Believe it or not, vaping, marijuana use, smoking, it all plays a role in your oral health…It’s an educational pitch, versus a judgemental one.
Believe it or not, most people do tell me about their smoking habits. I would say – and Iâm guessing here – about 20% don’t tell it on the forms, and it is discovered during conversation. The number one reason for it not being mentioned on the form is that they are with a family member with whom they don’t want the information shared (usually a mom not wanting a child to know) and then it is discussed further during x-rays or during their prophylactic appointment.
Dr. Melissa Beadnell, D.M.D.Â
Q: If patients admit to smoking marijuana, do you have suggestions or tips on what they can do to mitigate the effects of smoking it?
A: One of the biggest concerns is the xerostomia associated with chronic marijuana usage and the increase in caries (cavities). There is the need to educate the patient not only on the oral effects of usage but to give detailed oral hygiene instructions and discuss their diet and consumption of sugary foods/beverages. I usually recommend a prescription level fluoride toothpaste (Ex: Prevident 5000), for some patients a more frequent hygiene recall, and to stay hydrated throughout the day with regular water consumption.
Q: Do you ask patients if they smoke marijuana on your intake forms?
A: Yes – itâs a standard question on our forms. Marijuana is legal in Oregon and has provided many of my patients with health benefits like pain reduction so as the years go by the I think the stigma associated with it will be lessened. On our form, we have a simple check box next to “Tobacco Usage” and “Marijuana Usage” followed by an open line for the amount â ____ # cigs/day   ______ # grams/day.â
Q: Do you have any suggestions or tips on how to verbally ask patients if they smoke marijuana for those that didnât disclose it in the forms. Also, do you have any idea how many people donât disclose on forms versus what you are told in person?
A: If I suspect marijuana usage based on the patientâs age, oral condition, teeth stain, etc but they marked “no” on their form, I typically start the conversation with “You know âJonâ, I am noticing that your mouth is quite dry. Â Have you noticed a decrease in your saliva or the feeling like you need to drink water frequently?” Based on their answer, I then will discuss the different reasons a patient can have a decrease in saliva (medication usage, smoking, etc). Â If this conversation doesn’t yield a “Yep – I have been smoking some” then I personally don’t press the issue. I just turn the conversation towards educating them about the condition of their mouth and how to protect their teeth and periodontal health. Â
I would say that I only encounter this situation with 5% of my patients – pretty low. I only have this conversation maybe a few times a year.
Dr. Jaffer ShariffÂ
Q: If patients admit to smoking marijuana, do you have suggestions or tips on what they can do to mitigate the effects of smoking it?
A: There is no current research that shows any therapy to counter the effects of smoking cannabis/marijuana on gum health, but you could educate them on those effects so that they reduce the frequency of use.
* Dr. Shariff is currently working on a paper involving the dose response of marijuana on gum disease severity.
Q: Do you ask patients if they smoke marijuana on your intake forms?
A: The questions we use for the research are as follows:
- Ever used marijuana or hashish?
- Age when patient first tried marijuana?
- Age when patient started regularly using marijuana?
- How often patient currently uses marijuana?
Q: Do you have any suggestions or tips on how to verbally ask patients if they smoke marijuana for those that didnât disclose it in the forms. Also, do you have any idea how many people donât disclose on forms versus what you are told in person?
A: Based on personal experience, nearly all of my patients in the clinic respond honestly about their marijuana use. However, I believe that I have noticed a percentage drop in truthfulness on the surveys.
Dr. Flora Momen-Heravi and Dr. Philip KangÂ
  
Q: If patients admit to smoking marijuana, do you have suggestions or tips on what they can do to mitigate the effects of smoking it?
A: We have a question regarding smoking in our medical history form, and we ask patients verbally about marijuana use after asking details and questions about smoking habits. The question which we usually ask is âDo you smoke marijuana? We are asking that because it is important in the course of periodontal treatment and outcome,â and patients usually understand that it is a non-judgmental environment and everything is toward their benefit.
Q: Do you have any suggestions or tips on how to verbally ask patients if they smoke marijuana for those that didnât disclose it in the forms. Also, do you have any idea how many people donât disclose on forms versus what you are told in person?
A: We also emphasize the benefit of quitting by saying âYou can get benefit in terms of general health, oral health, and periodontal disease from reducing the number of times you use marijuana and ideally quitting the marijuana smokingâ. However, some patients refuse to change the habit or quit. We emphasize on an improvement of oral hygiene for these patients which can mitigate adverse oral health outcomes. We do not know how many people do not disclose this on our forms.
Dr. David EvansÂ
Q: If patients admit to smoking marijuana, do you have suggestions or tips on what they can do to mitigate the effects of smoking it?
A: The main tip I give is to brush thoroughly after smoking, and to avoid alcohol and alcohol containing mouth rinses. The combination of alcohol and smoking increases the risk of oral cancer significantly.
Q: Do you ask patients if they smoke marijuana on your intake forms?
A: Our intake and medical history form asks patients if they “use tobacco”, and “Do you use controlled substances?”
Q: Do you have any suggestions or tips on how to verbally ask patients if they smoke marijuana for those that didnât disclose it in the forms. Also, do you have any idea how many people donât disclose on forms versus what you are told in person?
A: I usually ask the patients directly during my new patient interview/exam if they smoke, and if they use marijuana. I run right down the form. Â I am not sure how many people don’t disclose it on our forms.
How To Discuss Marijuana Use With Your Patients
The legal industry has made it easier to discuss marijuana use openly with patients, but sometimes the topic can still be tricky. Patients may get defensive or prefer not to discuss recreational or medical habits and needs, but patient/doctor communication is increasingly important in this area.
Whether itâs by including a box to check for cannabis use in the ârecreational habitsâ section on a patient intake form (much like tobacco or alcohol) or simply by asking non-invasive questions, itâs possible for health practitioners to open a dialogue with their clients about their general habits and health. In her article, Suzanne Hubbard discusses a few of the ways that doctors can approach the subject without the topic of cannabis use becoming uncomfortable, and weâve included a short list, as well as a few tips for patients.
For Doctors:
- Include a simple check-list on the patient intake forms, alongside tobacco and alcohol use. The health practitioner can then proceed with awareness, and by providing this option for the patient to supply this information on their paperwork simplifies this process by making it easier for patients to respond without direct questioning.
- If direct questioning is required, doctors can ease gently into it, by starting with tobacco/alcohol use first, and then including cannabis use as a follow-up to the initial dialogue. If the patient becomes uncomfortable (paying attention to body language is important), doctors can not press the subject and perhaps consider reopening the conversation another time.
- Reminding patients to swish, floss, and brush daily to improve their overall oral health is a good way to get the importance of great hygiene across without digging too deeply.
For Patients:
- Being open with your doctor(s) is essential for your well-being, and by making your doctor aware of any habits that will impact your health over time, they will be more able to provide the care you will need. In light of the legalization of both medical and recreational cannabis in many states, it is important to be transparent and be open to discussing this habit with any of your health care providers, much like tobacco and alcohol use.
- Brush, floss, and even rinse daily for optimum oral health. Keeping sugary foods and drinks to a minimum and making sure you see your dentist regularly can help decrease your risk factors for poor oral health.
